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Provider Manual

Revised July 2018

Piedmont Community Health Plan Provider Manual (Manual), as may be amended from time to time,

is incorporated by reference to the Agreement. The Manual is designed for use by, and applicable to,

all Piedmont Participating Providers. The Manual supports all applicable federal and state laws,

regulations and policies as promulgated through Centra Health.

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PURPOSE AND INTRODUCTION

ABOUT PIEDMONT COMMUNITY HEALTH PLAN

Mission

Our mission is to provide comprehensive quality healthcare coverage to the residents of Central

Virginia and neighboring communities in partnership with those who share a commitment of

access to medical care that represents the highest standards for quality and efficiency.

Vision

Our vision is to provide efficient and quality healthcare coverage to the local community through

a network of physicians and hospitals. By doing so, we help hold down healthcare costs through

medical management efforts and lower administration costs. Superior customer service, account

management, and claims administration will be key components of success.

Values

• We are committed. We conduct ourselves in a manner that adheres to compliance and

organizational integrity and promotes both the letter and spirit of the Code.

• We are dedicated. We learn the laws and regulations that govern our business and are

diligent in keeping current on regulatory changes.

• We are honest. We comply with laws and regulations and monitor actions for

reasonableness, necessity, accuracy, appropriateness and completeness.

• We use good judgment. We do not engage in any activity that might create a conflict

of interest for ourselves or the company.

• We are courageous. We speak up for what is right. We report wrongdoing when we

see it including illegal or unethical conduct, fraud, waste, and abuse.

• We are responsible. We accept the consequences of our actions. We admit our

mistakes and quickly fix them. We don’t retaliate against those who try to do the right

thing by asking questions or raising concerns.

• We are trustworthy. We protect the privacy of our members and the confidentiality

of sensitive business information about Piedmont.

• We treat others with respect. We value our members, colleagues, and community

and maintain fairness in all relationships. We are open and transparent in our

communications with each other.

As part of the Centra Health System, we operate on the principles that a personal physician

should manage the healthcare of our members -- not out-of-town insurance administrators -- and

that there should be close cooperation between local healthcare providers, patients and

employers.

Our provider network includes more than 98 percent of the area’s physicians, other healthcare

professionals, and the full resources of the Centra Health system.

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Our primary service area includes the city of Lynchburg and the counties of Albemarle, Amherst,

Appomattox, Bedford, Buckingham, Campbell, Cumberland, Lunenburg, Nottoway and Prince

Edward. We also serve members in portions of Charlotte, Halifax, Mecklenburg, Nelson and

Pittsylvania counties.

We offer three basic plan designs to local large or small employers: Point of Service (POS)

plans, Preferred Provider Organization (PPO) plans, and Point of Service – Health Maintenance

Organization (POS-HMO) plans. These plan designs are offered through a choice of funding

arrangements. Self-insured arrangements are provided through the parent company, Piedmont

Community Health Plan. Fully insured arrangements are provided through our wholly owned

subsidiary, Piedmont Community HealthCare. All utilize the same Piedmont Community Health

Plan network of providers.

Piedmont Advantages

Piedmont Community Health Plan and Piedmont Community HealthCare offer real advantages

to members and employers including:

• A community-based organization accessible to its members.

• Local management with local knowledge and understanding to make the most

informed decisions.

• Local staff empowered to serve each employer and their covered employees.

• A medical management program designed by the local medical community which

promotes the concept that your physician will manage your care.

Piedmont is Central Virginia's only locally headquartered healthcare insurance carrier offering

individual Marketplace plans in accordance with the Affordable Care Act. We offer competitive

rates in addition to the desired benefits set forth by the Affordable Care Act on both our

individual and family health plans. Members may choose between Gold, Silver, or Bronze plans.

Piedmont takes pride in being the only local Medicare Advantage plan in Central Virginia. We

believe we know what Virginians want in a health plan and our plans are strategically designed

with our beneficiaries’ needs in mind.

With over 20 years of commercial health care experience, Piedmont set the standard for quality

of care. In our continuous effort to provide local coverage and service to the community in which

we serve, Piedmont began offering Piedmont Medicare Advantage (PPO) in 2011. Piedmont

Medicare Advantage is dedicated to quality of care initiatives specifically designed to encourage

health and wellness.

Contact Information

Piedmont Community Health Plan

2316 Atherholt Road

Lynchburg, Virginia 24501

Phone: 434-947-4463

Office hours: 8:30 to 5:00 p.m., Monday through Friday except holidays.

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Director of Provider/Client Relations: Barb Schlesinger-Nash, 434-947-4463, ext. 223

CVSCaremark: 1-800-966-5772

CVSCaremark Medicare Advantage: 1-866-494-9927

Visit Piedmont’s provider web portal at www.pchp.net to perform the following:

• View benefits

• View claims

• View eligibility

• Access Network Participation Request Form (credentialing for physicians/practitioners)

• Access Prior Authorization List and other provider forms

• Conduct provider and formulary searches

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PROVIDER RESPONSIBILITIES

General Provisions

Participating Provider and Piedmont agree to abide by the following General Provisions:

Assignment. The Agreement or any part, articles or sections thereof may not be assigned during

the term of the Agreement by any of the parties without the prior written consent of the other

party(s), except (i) as may otherwise be provided for in the Agreement and (ii) each party may at

any time assign its rights and obligations under the Agreement to any corporation controlled by,

in control of or under common control of the assigning party provided, however, it provides the

non-assigning party(s) with thirty (30) days prior to written notice of said assignment.

Compliance. The parties agree to comply with all applicable federal and state laws and rules

including, but not limited to (i) Title VII of the Civil Rights Act of 1964; (ii) The Age

Discrimination Act of 1975; (iii) The Rehabilitation Act of 1973; (iv) The Americans With

Disabilities Act; (v) other laws applicable to recipients of Federal funds; (vi) Medicare laws,

regulations and Centers for Medicare and Medicaid Services (CMS) instructions; (vii) Patients’

bill of Rights in accordance with OPM; (viii) the Genetic Information Nondiscrimination Act of

2008; (ix) Health Insurance Portability and Accountability Act of 1996 (HIPAA); and all other

applicable laws and rules. Furthermore, Participating Provider hereby warrants and represents

that it shall comply and shall be responsible for requiring any party that it may subcontract with

to furnish services to Members to comply with Piedmont’s policies and procedures and all other

terms and conditions of the Agreement. Additionally, it is hereby disclosed that payments made

by Piedmont to related entities, contractors and subcontractors are, in whole or in part, from

federal funds received by the Piedmont through its contracts with the Centers for Medicare and

Medicaid Services.

Entire Agreement/Amendments/Multiple Originals. The Agreement, together with any

attachments, exhibits, or applicable Provider Manual(s), as amended from time to time, set forth

the entire Agreement between the parties with respect to the subject matter. Any prior purchase

orders, agreements, promises, negotiations or representations, whether oral or written, not

expressly set forth in the Agreement, are of no force or effect. The Agreement shall be executed

in multiple originals, one for Participating Provider and the other for Piedmont. The parties agree

that the Agreement shall be automatically amended to comply with applicable federal and state

laws and regulations; otherwise, the Agreement may not be amended except in writing, signed by

the parties.

Exhibits. All exhibits within the Agreement are incorporated by reference and made part of the

Agreement as if they were fully set forth in the text of the Agreement.

Governing Law. The Agreement shall be deemed to have been made and shall be construed and

interpreted in accordance with the laws of the Commonwealth of Virginia, and the parties hereto

agree to the jurisdiction of the Commonwealth of Virginia.

Indemnification. Participating Provider and Piedmont agree to protect, indemnify and hold

harmless the other party(s) from and against any and all loss, damage, cost and expense

(including attorneys’ fees) which may be suffered or incurred under the Agreement as a result of

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the negligent or intentional acts of the indemnifying party, its employees, agents, consultants or

subcontractors. Said indemnity is in addition to any other rights that the indemnified party may

have against the indemnifying party and will survive the termination of the Agreement.

Insurance. The parties agree to maintain, at its own cost and expense, insurance coverage as

necessary and reasonable to insure itself and its employees and agents in connection with the

performance of its duties and responsibilities under the Agreement. Upon request, the parties

agree to provide one another with a Certificate of Insurance evidencing said insurance coverage.

Participating Provider shall notify Piedmont within ten (10) days of the cancellation or material

alteration of such coverage.

Notices. All notices and communications hereunder shall be in writing and deemed given, when

personally delivered to or upon receipt when deposited with the United States Postal Service,

certified or registered mail, return receipt requested, postage prepaid; a nationally recognized

overnight courier, with all fees prepaid; or e-mail addressed as set forth on the first page of the

Agreement or to such other person and/or address as the party to receive may designate by notice

to the other.

Notification of Incidents. The parties agree to notify the other party (s) within twenty-four (24)

hours after the discovery of any incidents, occurrences, Claims or other causes of action

involving the Agreement. Upon receipt of discovery by any party of any incident, occurrence,

Claim (either asserted or potential), notice of lawsuit or lawsuit involving the Agreement, said

party agrees to immediately notify the other party(s). The parties hereto agree to provide

complete access, as may be provided by law, to records and other relevant information as may be

necessary or desirable to resolve such matters. This Section shall survive the termination of the

Agreement.

Other Parties. The Agreement is solely between the parties hereto and is not intended to be

enforceable by any other party or to create any express or implied rights hereunder of any nature

whatsoever in any other party.

Partial Invalidity/Interpretation. If any term or provision of the Agreement is determined to be

invalid or unenforceable, the remainder of the Agreement will not be affected thereby. The

section headings in the Agreement are solely for reference purposes. Participating Provider

acknowledges that portions of the Agreement are subject to review by Governmental Agencies

and/or their designated representatives, as applicable, and in the event that such Governmental

Agencies and/or their designated representatives require any material change to the terms and

conditions of the Agreement, Participating Provider agrees to renegotiate the affected terms and

conditions upon being notified of such required change by Piedmont.

Promotional Materials. Participating Provider consents to Piedmont’s use of its name, address

and the names and professional designations of its healthcare professionals in traditional

membership and marketing materials. The parties hereto agree not to use the name of or any

trademark, service mark or design registered to the other parties or their affiliates or any other

party in any additional publicity, promotional or advertising material, unless review and written

approval of the intended use shall first be obtained from the releasing party(s) prior to the release

of any such material. Said approval shall not be unreasonably withheld by any of the parties.

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Relationship Among Parties. The parties hereto expressly acknowledge and agree that: (i)

Piedmont’s duties and responsibilities under the Agreement apply solely to Piedmont Members;

(ii) in its capacity as third-party administrator, Company’s duties and responsibilities under the

Agreement apply to Members of an Employer- Sponsored Program; and (iii) with the exception

of (ii) of this Section, Company’s duties and responsibilities under the Agreement apply to

Company Members. Each party hereto shall be considered independent entities with respect to

each other. None of the provisions of the Agreement are intended to create nor shall be deemed

or construed to create any relationship between the parties other than that of independent entities

contracting with each other solely for the purpose of effecting the provisions of the Agreement.

Neither the parties nor any of their respective agents or employees shall be construed to be the

agent, employee, joint Employer or representative of the other. The parties shall not have any

express or implied rights or authority to assume or create any obligation or responsibility on

behalf of or in the name of the other, except as may be otherwise set forth in the Agreement.

Release of Information. The provisions of the Agreement are confidential and protected from

disclosure to any other party unless: (i) otherwise provided for in the Agreement; (ii) disclosure

is required by Piedmont, an Employer or Participating Provider to meet any federal, state or local

rule, law or regulation; or (iii) any party hereto engages a third party for purposes such as quality

assurance or auditing.

Unforeseen Circumstances. In the event either party’s operations are substantially interrupted

by war, fire, insurrection, the elements, earthquakes, acts of God or, without limiting the

foregoing, any other cause beyond the control of the affected party (including the Piedmont no

longer meeting all material requirements imposed on Piedmont by Federal or State law resulting

in a significant impact on Piedmont’s operations), the affected party shall be relieved of its

obligations only as to those affected portions of this Agreement for the duration of such

interruption. In the event that the performance of the affected party hereunder is substantially

interrupted pursuant to such event, the other party shall have the right to terminate this

Agreement upon ten (10) days’ prior written notice to the affected party.

Waiver. Failure of a party to complain of any act or omission on the part of another party shall

not be deemed to be a waiver. No waiver by a party of a breach of the Agreement will be deemed

a waiver of any subsequent breach. Acceptance of partial payment will be deemed a part

payment on account and will not constitute an accord and satisfaction.

Primary Care Providers (PCPs)

A Primary Care Practitioner (PCP) is a specific physician, physician’s assistant (PA), physician

group, or a Certified Registered Nurse Practitioner (CRNP) operating under the scope of his/her

licensure, who is responsible for supervising, prescribing, and providing primary care services;

locating, coordinating and monitoring other medical care and rehabilitative services and

maintaining continuity of care on behalf of the Member. Additional PCP responsibilities include,

but are not limited to:

1. Providing primary and preventive care and acting as the Member’s advocate,

providing, recommending and arranging for care.

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2. Documenting all care rendered in a complete and accurate encounter record that

meets or exceeds the DHS data specifications.

3. Maintaining continuity of each Member’s health care.

4. Communicating effectively with the Member by using sign language interpreters for

those who are deaf or hard of hearing and oral interpreters for those individuals with

LEP when needed by the Member. Services must be free of charge to the Member.

5. PCPs are responsible for initiating and coordinating referrals of Members for

Medically Necessary services beyond the scope of their contract of practice. PCPs

must monitor the progress of the referred Members’ care.

6. Maintaining a current medical record for the Member, including documentation, of all

the services provided to the Member by the PCP, as well as any specialty or referral

services.

Member Assignment to PCP and Assignment of Newborns

Assignment of members to a PCP is the member’s responsibility. Piedmont does not assign

members to PCPs. Piedmont will help members identify a network PCP and will not attempt to

steer members to any PCP within its network. If a member does not provide Piedmont with the

name of their PCP, Piedmont will assign the PCP or specialist who has been most involved in the

member’s ongoing medical care. Newborns are immediately enrolled in the program and all

Medically Necessary services are provided to newborns. Piedmont makes every effort to identify

what PCP/pediatrician the mother chooses to use for the newborn prior to the birth, so that the

provider chosen by the parent can be assigned to the newborn on the date of birth.

Changing PCPs

Piedmont members may change PCPs at their discretion. When a PCP is not named by the

member, Piedmont will attribute the member to the PCP or specialist who has been most involved

in the member’s ongoing medical care.

Specialty Care Providers (SCPs)

The PCP is responsible for initiating, coordinating and documenting referrals to Specialty Care

Providers (SCPs) within the Piedmont Network. Members may request a second opinion from

providers within the Network. If there is not a second provider with the same specialty in the

Network, Members may request a second opinion from a provider out of Network at in-network

level of benefit.

SCPs must coordinate with the PCP when Members need a referral to another provider. Upon

request, such records must be shared with the appropriate providers and forwarded at no cost to

the Member or other providers. SCPs are responsible for obtaining referrals from referral

physicians and bringing referred Members into compliance with medical treatment plans.

Members with a disease or condition that is life threatening, degenerative, or disabling may

request a medical evaluation. If evaluation standards are met, Members receive one of the below:

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1. A standing referral to a SCP for treatment of their disease or condition. If a Member

needs ongoing care from a SCP, Piedmont will authorize, if Medically Necessary, a

standing referral to the SCP with clinical expertise in treating the Member’s disease or

condition. In these cases, Piedmont may limit the number of visits or the period during

which such visits are authorized and may require the SCP to provide the PCP with

regular updates on the specialty care provided, as well as all necessary medical

information.

2. A designated SCP to provide and coordinate both primary and specialty care for the

Member. The SCP treating the Member’s disease or condition will serve as the Member’s

PCP, coordinating care and making referrals to other SCPs, as needed.

Please refer to Medical Management & Prior Authorizations section of this Manual for more

information.

SCP as PCP

A Member may qualify to select a SCP to act as PCP if she/he has a disease or condition that is

life threatening, degenerative, or disabling The SCP as a PCP must agree to provide or arrange

for all primary care, consistent with Piedmont preventive care guidelines, including routine

preventive care, and to provide those specialty health care services consistent with the Member's

“special need” in accordance with Piedmont standards and within the scope of the specialty

training and clinical expertise.

PCPs are responsible for initiating and coordinating referrals of Members for Medically

Necessary services beyond the scope of their contract of practice. PCPs and SCPs must monitor

the progress of the referred Members’ care and SCPs must see that Members are returned to the

PCP’s care as soon as medically appropriate.

Appointment Standards

These requirements assume that the receiving facility has both the capability and capacity to

provide the required services. Emergent referrals for both primary and specialty care are

expected immediately and will occur in accordance with all EMTALA standards when an

Emergency Department is involved. It is expected that emergent referrals to a specialty clinic

receive the appropriate medical screening, stabilization, treatment, and referral to a higher level

of care when necessary. Urgent referrals are expected to be evaluated within 24 hours for both

primary and specialty services. Routine primary care referrals are expected to have an

appointment scheduled within 10 business days and specialty appointments within 15 business

days. Again, these referral standards assume the clinic that is referred to has the capability and

capacity to meet these standards. When a clinic is unable to meet these standards, the member

should be informed and given the option to be referred to a different clinic if they are unable or

unwilling to wait.

PCP Wait Times

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Waiting time standards for PCPs require that Members, on average, should not wait at a PCP

office for more than thirty (30) minutes for an appointment for routine care. On rare exceptions,

if a physician encounters an unanticipated urgent visit or is treating a Member with a difficult

medical need, the waiting time may be expanded to one hour. Piedmont monitors compliance

with appointment and waiting time standards and works with providers to ensure that these

standards are met.

Appointment Notification and Follow-Up

The PCP or SCP is required to conduct affirmative outreach whenever a Member misses an

appointment and to document this in the medical record. Such an effort shall be deemed to be

reasonable if it includes three (3) attempts to contact the Member. Such attempts may include,

but are not limited to: written attempts, telephone calls and home visits. At least one (1) such

attempt must be a follow-up telephone call. Communications with the Member should take the

language and literacy capabilities of Members into consideration.

Infection Control Measures

Piedmont wants to ensure providers exercise approved and effective infection control practices.

The Guide to Infection Control Prevention for Outpatient Settings: Minimum Expectations for

Safe Care, produced by the Centers for Disease Prevention can be found at

http://www.cdc.gov/HAI/pdfs/guidelines/standatds-of-ambulatory-care-7- 2011.pdf.

Quality Management Plan

Piedmont’s mission is to provide comprehensive quality healthcare coverage to the residents of

Central Virginia and neighboring communities in partnership with those who share a

commitment of access to medical care that represents the highest standards for quality and

efficiency. Piedmont supports the overall mission of Centra. The Piedmont Quality Management

(QM) Plan provides the structure and processes for continuously monitoring, analyzing, and

improving the clinical care and services provided under Piedmont products to further that

mission.

A copy of the complete QM Plan can be requested from Piedmont's Quality Improvement

Department.

REFERRALS

Direct Access and Self-Referrals

The following services do not require a referral from the PCP:

1. Vision (only if for routine; if medical in nature, may require authorization)

2. Dental (only if for routine; if medical in nature, may require authorization)

3. Obstetrical and Gynecological (OB/GYN) services

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4. Chiropractic services

5. Physical, occupational and speech therapy services

Please Note: To be self-referred, the Member must obtain these self-referred services from

Piedmont’s Network.

Family Planning Services do not require Prior Authorization or referral. Members may access

Family Planning Services from any qualified provider. Family Planning Services include, but are

not limited to:

• Health Education

• Counseling necessary to make an informed choice about contraceptive methods

• Pregnancy testing and breast and cervical cancer screening services

• Contraceptive supplies such as oral birth control pills, diaphragms, foams, creams, jellies,

condoms (male and female), Norplant, injectables, intrauterine devices, and other family

planning procedures

• Diagnostic screens, biopsies, cauterizations, cultures, and assessments

Members have direct access to OB/GYN services and have the right to select their own OB/GYN

provider; this includes nurse midwives participating in Piedmont’s Network. They can obtain

maternity and gynecological care without prior approval from a PCP. This includes:

• Selecting a provider to give an annual well-woman gynecological visit

• Primary and preventive gynecology care

• PAP smear and referrals for diagnostic testing related to maternity and gynecological

care, and Medically Necessary follow-up care

• Perinatal and Postpartum maternity care

If a new pregnant Member is already receiving care from an Out-of-Network OB-GYN SCP at

the time of enrollment, the Member may continue to receive services from that SCP throughout

the pregnancy and postpartum care related to the delivery. In such cases, please notify Medical

Management to ensure your record is appropriately notated.

Substance Abuse and Behavioral Health Referrals

Many behavioral health disorders such as depression, anxiety and substance abuse often occur in

Members who present for medical care. PCPs and all non-behavioral health practitioners are

encouraged to recommend behavioral health services to Members when deemed appropriate.

Substance abuse and behavioral health services, when appropriate authorizations are obtained,

are available to all Piedmont Members through the Member’s local county mental health services

and/or other Network providers.

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UTILIZATION MANAGEMENT PROGRAM AND CRITERIA

Participating Providers are reminded that utilization criteria and the utilization program description

are available upon request. Participating Providers may request a copy of the applicable criteria as

part of the utilization decision phone conversation, by fax or U.S. mail, or through discussion with

the respective Medical Director. Criteria can be requested in writing from the Medical

Management Department, Attention: Director of Medical Management, 2316 Atherholt Road,

Lynchburg, Virginia 24501.

Utilization Management (UM) Definitions

1. Pre-service Review. Review for Medical Necessity that is conducted on a health care

service or supply prior to its delivery to the Covered Individual.

2. Initial Request/Continued Stay Review (continuation of services). Review for Medical

Necessity during initial/ongoing inpatient stay in a facility or a course of treatment,

including review for transitions of care and discharge planning.

3. Pre-certification/Pre-authorization Request. For UM team to perform Pre-service

Review, the provider submits the pertinent information as soon as possible to Piedmont

UM prior to service delivery.

4. Pre-certification/Pre-authorization Requirements. List of procedures that require Pre-

service Review by UM prior to service delivery.

5. Business Day. Monday through Friday, excluding designated company holidays.

6. Notification. The telephonic and/or written/electronic communication to the applicable

health care Providers, Facility and the Covered Individual documenting the decision, and

informing the health care Providers, Facility and Covered Individual of their rights if they

disagree with the decision.

Prior Authorizations (Precertification)

Precertification is Piedmont’s response to information presented relating to a request for specified

health care services. Precertification does not guarantee a Member’s coverage or Piedmont

payment. A Member’s coverage is pursuant to the terms and conditions of coverage set forth in a

Member’s applicable benefit document.

A Member is not financially responsible for a Participating Provider’s failure to:

(i) obtain precertification, or

(ii) provide required and accurate information to Piedmont.

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Copayments are the financial responsibility of the Member, when applicable.

A complete list of services requiring Prior Authorization is available online at www.pchp.net.

General Rules for Pre-Certification

Not all health plans offer the same benefits. Always confirm benefits that may be available for the

Covered Individual at the time of service either online through the PCHP website or by calling

Customer Service at the phone number on the Covered Individual’s health plan ID card. Please

note: Customer service cannot provide pre-certification for services. Providers still must call the

pre-certification line phone number on the Covered Individual’s health plan ID card

Pre-certification, or the requirement for it, is not a guarantee of benefits. Once pre-certification is

obtained, to facilitate timely and accurate processing of claims, the ordering provider must verify

the Covered Individual’s eligibility within two (2) business days before providing services.

For services obtained from non-participating providers, benefits may not be available, Covered

Individual financial responsibility may increase or reimbursement to providers may be reduced,

depending on the Covered Individual’s Health Benefit Plan. If a non-participating provider is

delivering services, Piedmont strongly advises that the Covered Individual and the non-

participating provider call Customer Service at the phone number on the Covered Individual’s

health plan ID card to confirm available benefits and to clarify financial responsibility, which may

make it possible to avoid any applicable financial penalties.

Authorization Required for Payment

Any service, with or without an authorization, rendered by a Participating Provider and determined

to be clinically inappropriate by the Medical Director will be paid at an appropriate alternate level

of care or payment will be denied completely. Medical Director determinations are in accordance

with individual Member’s needs, characteristics of the local delivery system, applicable medical

criteria and clinical expertise. At the time of a claim payment denial, the Participating Provider is

verbally notified of the option to speak with a Medical Director regarding such payment denial.

The Provider Appeal process is also available to Participating Providers for claims payment issues.

Precertification Determination and Communication

Precertification of services may be required and will be performed by Piedmont Medical

Management staff, or through delegated vendor relationships. Delegated vendors may review

services such as, but not be limited to, pharmacy requests.

Precertification staff, which includes appropriate practitioner reviewers, utilizes nationally

recognized medical guidelines as well as internally developed medical benefit policies, individual

assessment of the Member, and other resources to guide precertification, Concurrent Review, and

Retrospective Review processes in accordance with the Member’s eligibility and benefits.

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Preferred Modes of Data Submission to Piedmont Medical Management

Piedmont prefers contracted providers utilize our Electronic Referral System (ERS) to submit

authorization requests and attach clinical information needed to conduct prior authorization.

Please note: Do not send the entire chart. Only send the applicable information such as admission

history and physical, pertinent lab and test information, physician progress notes, etc.

Provider may also send in via fax a request for services. Fax: 434-947-4465

Urgent requests can also be called to Piedmont’s Medical Management Department at 434-947-

4463.

Please note: Piedmont is available to accept authorization requests during off hours via fax, ERS

or voicemail.

How to Obtain Pre-Certification

Please have the following information available when you request pre-certification:

• Covered Individual’s name, identification number, and date of birth

• Diagnosis including ICD-10 code, scheduled procedure including CPT codes, and date of

admission or expected date of service

• Name of the referring provider and referring to provider or facility

• The Covered Individual’s medical records (Please have them in front of you because you

will be asked specific questions about the Covered Individual’s past treatment and ongoing

medical condition. In some cases, you may be asked to submit additional information in

writing.)

Upon receipt of the pre-certification request, Piedmont’s medical management department staff

will:

• Confirm Covered Individual eligibility

• Verify the Covered Individual’s insurance coverage.

• Evaluate Medical Necessity

Upon submission of required information, the precertification staff will provide the Member, the

requesting provider and the prescribing provider with notification of the determination of coverage

as expeditiously as the Member’s health condition requires, or at least orally, within the standard or

expedited required timeframe of receiving the request, unless additional information is needed.

Piedmont will make standard requests for services within 14 days of receipt or prior to the date of

service if date is sooner than 14 days after receipt. For expedited request, Piedmont will provide a

decision within 72 hours. For concurrent review, decisions will be made within 24 hours of the

receipt of information. Notification will be made to providers and members within the above

allotted timeframes as well. Piedmont may request additional information and take an extension

when the extension will be in the best interest of our member.

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On-Site Review

If Plan maintains an on-site Initial Request/Continued Stay Review program, the Facility’s UM

program staff is responsible for following the Covered Individual’s stay and documenting the

prescribed plan of treatment, promoting the efficient use of services and resources, and facilitating

available alternative outpatient treatment options. Facility agrees to cooperate with Piedmont and

provide Piedmont with access to Covered Individuals medical records, as well as, access to the

Covered Individuals in performing on-site Initial Request/Continued Stay Review and discharge

planning related to, but not limited to, the following:

• Emergency and/or maternity admissions

• Ambulatory surgery

• Case management

• Pre-admission testing (PAT)

• Inpatient Services, including Neo-Natal Intensive Care Unit (NICU)

• Focused procedure review Discharge Planning

• Observation stays

Discharge planning includes the coordination of medical services and supplies, medical personnel

and family to facilitate the Covered Individual’s timely discharge to a more appropriate level of

care following an inpatient admission.

Urgent/Emergency Services

PCP authorization are not required for Emergency Services. PCPs agree to have health care

services available and accessible to Members, twenty-four (24) hours per day, and seven (7) days

per week. When the PCP is not available and accessible to Member, the PCP is responsible for

ensuring appropriate arrangements are made for another PCP to provide Health care services to

Member, in accordance with Piedmont Access and Availability Standards.

PCPs can utilize the following to ensure Members have access to medical direction or care:

• PCP can utilize an answering service that forwards callers (i.e., Members) directly to the

PCP or a designated covering PCP for medical direction or care during PCPs non-business

hours.

• PCP can utilize any other delivery method that would provide the Member with direct

access to the PCP or designated covering PCP with medical direction or care during PCPs

non-business hours.

Participating Provider’s specialty services immediately following an emergency department

discharge or an inpatient hospital discharge, whether in or outside the mandatory post-operative

period, excluding direct access services, require a Referral Form issued by the Member’s PCP for

HMO and some POS plans. Please contact CS if there are questions about necessity based on

member’s plan.

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Behavioral Health and Substance Abuse Services

Piedmont encourages all health care providers to be cognizant of the impact that behavioral health

problems may have on physical health, to treat the Member accordingly and to refer to, and

coordinate with, a behavioral health specialist when necessary. Providers are encouraged to be

holistic in their approach and to promote the integration of behavioral health and physical health

services in their Member’s care. All contact with behavioral health providers needs to be conducted

in accordance with state and federal privacy policies in effect at the time.

Coordination of care with behavioral health providers is strongly encouraged and especially

important for Members who present with physical health problems in addition to:

• ·Chronic history of depression, anxiety or substance abuse/dependence.

• ·Multiple psychotropic medications.

• ·New prescriptions for atypical anti-psychotics and/or antidepressants when Member is

taking medication for a medical condition.

• ·Those with a substance abuse problem and prescribed potentially addictive medication.

• ·Pregnant women who require medication to manage a behavioral health condition.

• ·Other conditions which may warrant this same coordination and collaboration of care

between Piedmont providers and behavioral health providers.

Cooperation between Participating Providers and behavioral health practitioners is critical to the

provision of effective and appropriate care. Participating Providers are expected to:

• Refer Members to appropriate behavioral health provider.

• Be available for consultation with the Member’s behavioral health practitioner.

• Seek release of information in cases of known behavioral health provider involvement.

• Abide by all privacy and confidentiality laws and regulations governing the sharing of

Protected Health Information.

• Assess all pregnant Members for depression, substance abuse and other behavioral health

problems, as well as nicotine dependence.

• Closely monitor any Members with diagnosis of diabetes and schizophrenia with special

attention to LDL-C and HbA1c.

• Coordinate and collaborate with behavioral health providers for those Members with

chronic medical conditions such as, but not limited to, CAD, CHF, COPD, Diabetes, etc.

Experimental/Investigational or Unproven Services

Experimental, investigational or unproven services are any medical, surgical, psychiatric, substance

abuse or other health care technologies, supplies, treatments, diagnostic procedures, drug therapies

or devices that are determined by Piedmont to be:

• ·Not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed

for the proposed use, or not identified in the American Hospital Formulary Service as

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appropriate for the proposed use, and are referred to by the treating Health Care Provider as

being investigational, experimental, research based or educational; or

• ·The subject of an ongoing clinical trial that meets the definition of a Phase I, II, or III

clinical trial set forth in the FDA regulation, regardless of whether the trial is subject to

FDA oversight; or

• ·The subject of a written research or investigational treatment protocol being used by the

treating Health Care Provider or by another Health Care Provider who is studying the same

service.

If the requested service is not represented by criteria listed above, Piedmont reserves the right to

require demonstrated evidence available in the published, peer-reviewed medical literature. This

demonstrated evidence should support:

• ·The service has a measurable, reproducible positive effect on health outcomes as

evidenced by well-designed investigations, and has been endorsed by national medical

bodies, societies or panels with regard to the efficacy and rationale for use; and

• ·The proposed service is at least as effective in improving health outcomes as are

established treatments or technologies or is applicable in clinical circumstances in which

established treatments or technologies are unavailable or cannot be applied; and

• ·The improvement in health outcome is attainable outside of the clinical investigation

setting; and

• ·The majority of Health Care Providers practicing in the appropriate medical specialty

recognize the service or treatment to be safe and effective in treating the particular medical

condition for which it is intended; and

• ·The beneficial effect on health outcomes outweighs any potential risk or harmful effects.

Piedmont reserves the right to make judgment regarding coverage of experimental, investigational

and/or unproven procedures and treatments. Participating Providers are encouraged to contact the

Medical Management Department for precertification review if the service could potentially be

experimental/investigational or potentially unproven services.

Failure to Comply with Utilization Management Program

Provider and Facility acknowledge that the Plan may apply monetary penalties such as a reduction

in payment, as a result of Provider's or Facility’s failure to provide notice of admission or obtain

Pre-service Review on specified outpatient procedures, as required under this Agreement, or for

Provider's or Facility’s failure to fully comply with and participate in any cost management

procedures and/or UM programs.

Peer to Peer Review Process

Providers can initiate a peer-to-peer request IF he/she is the attending, treating or ordering

physician, Nurse Practitioner, or Physician Assistant who provides the care for which any adverse

Medical Necessity determination is made. In compliance with nationally recognized guidelines

from the National Committee for Quality Assurance (NCQA). Provider or his/her designee may

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request the peer-to-peer review. Others such as hospital representatives, employers and vendors are

not permitted to do so.

Audits/Records Requests

At any time, Piedmont may request on-site, electronic or hard copy medical records, utilization

review sheets and/or itemized bills related to Claims for the purposes of conducting audits and

reviews to determine Medical Necessity, diagnosis and other coding and documentation of services

rendered.

CASE MANAGEMENT

The purpose of Piedmont’s Complex Case Management Program is to ensure that medically

necessary care is delivered in the most cost-efficient setting, utilizing the most appropriate

provider(s), and in the most cost-efficient manner and timeframe for members who require

extensive or ongoing services. The program is focused on improving access to needed resources for

members with complex and chronic care issues.

Proactive clinical and administrative processes are implemented to identify, coordinate, and

evaluate appropriate high-quality services that may be delivered on an ongoing basis. The Complex

Case Management Program is evaluated, updated and approved annually along with the Utilization

Management Program.

The Complex Case Management process is directed at coordinating resources and creating

appropriate cost-effective alternatives for catastrophically, chronically ill or injured members on a

case-by-case basis to facilitate the achievement of realistic treatment goals. Medical Directors

assist in making decisions of medical appropriateness for the Complex Case Management process.

Qualified and appropriately licensed health professionals are involved in the Complex Case

Management Program. Case managers coordinate individual services for members whose needs

include ongoing medical care, home health and hospice care, rehabilitation services and preventive

services. The case managers work collaboratively with those involved in the member’s care,

including discharge planners, care managers, and/or care navigators at hospitals, SNFs, other

healthcare facilities, and ambulatory settings (e.g., PCMH). Piedmont conducts hospital rounds for

utilization review and discharge planning at our local hospitals including having staff on-site to

meet with members, caregivers, and attending physicians to assist in the care of our members. The

medical director and Utilization Management Committee members are substantially involved in

these case management functions.

The goal of Complex Case Management is to help members regain optimum health or improved

functional capability in the right setting and in a cost-effective manner. It involves comprehensive

assessment of the member’s condition; determination of available benefits and resources; and

development and implementation of a case management plan with performance goals, monitoring

and follow up. Complex Case Management differs from other health plan interventions in that the:

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• degree and complexity of illness or condition is typically severe.

• level of management necessary is typically intensive.

• amount of resources required for member to regain optimal health or

improved functionality is typically extensive.

Case managers work in collaboration with the primary care physician to manage patients with

complex co-morbid conditions. The case manager completes a comprehensive assessment and

prioritizes the patient’s needs that allow the provider, member and/or member representative, and

case manager to develop a patient-centric action plan of care and self-management. Post discharge

transitions of care are integral to this patient-centered model and include medication reconciliation,

confirmation that services such as home health, durable medical equipment, and adequate social

support, are in place. For advanced illnesses, case managers will facilitate palliative care, home

health and hospice referrals.

To refer a Member to a Case Management/Disease Management Program or to learn more about a

specific Case Management/Disease Management Program, providers should visit Piedmont’s

Provider Information Center at www.pchp.net or contact the Case Management Department at

(434) 947-4463 or toll free (800) 400-7247, Monday through Friday from 8:00 a.m. to 5:00 p.m.

DISEASE MANAGEMENT PROGRAM DEVELOPMENT

The Case Management Department conducts an analysis of the disease under consideration prior to

the development of a Case Management/Disease Management program. The following criteria are

evaluated:

• Disease prevalence

• Disease complexity

• Potential for reducing complications, improving quality

• Current cost of managing the disease

• Existence of an evidence-based clinical guideline to assist practitioners in the management

of the disease

• Value to the Participating Provider, Member and Piedmont if the program is implemented

Case Management leadership determines the need for a specific Case Management/Disease

Management program based upon the criteria listed above and submits a proposal to Piedmont’s

Quality Improvement Committee for review and approval. Actively practicing practitioners are

participating members of Case Management/Disease Management teams and they assist in the

development, implementation, and monitoring of new and established Case Management/Disease

Management programs.

Practitioner Program Content

The design of all Case Management/Disease Management programs includes, but is not limited to:

evidence-based clinical guidelines, Member identification, passive or active enrollment,

stratification, interventions based on stratification level, practitioner decision support and

evaluation of program effectiveness.

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Evidence-based clinical guidelines are a core component of Piedmont medical management

programs. Board certified SCPs and/or PCPs are involved in the review and approval of evidenced-

based guidelines.

Clinical guidelines are reviewed every two years or when the appropriate guideline team,

Piedmont’s Utilization Management Committee and/or the Quality Improvement Committee make

recommendations. Identified primary and SCPs are involved in the development and review of new

Case Management/Disease Management programs.

Piedmont’s Case Management Department and the accompanying teams are responsible for

program content that is consistent with current clinical practice guidelines.

Evidence-based guidelines are posted online at www.pchp.net and announcements are made in the

provider newsletter. Printed copies or electronic PDF files are available upon request for

practitioners who do not have Internet access.

Identification of Members who benefit from Case Management/Disease Management programs is

accomplished through Claims analysis using standard clinical specifications from criteria such as

the Health Plan Employer Data & Information Set (HEDIS®). Member identification is also

facilitated by direct referrals from PCPs, SCPs, family members, or from various Piedmont

departments including Medical Management, Customer Service, Appeals, and Quality

Improvement.

Enrollment and Patient Participation

All members with a disease-specific diagnosis are identified by claims analysis and/or HEDIS®

criteria.

All enrollees receive disease-specific informational newsletters each year to increase their

knowledge of disease self-management. The newsletters also encourage members to become

“active” participants in the disease management program.

A member can be enrolled in the appropriate disease management program by contacting

Piedmont’s Case Management Department directly or by referral from a Health Care Provider or a

Piedmont department, or by accepting an invitation extended by Piedmont’s Case Management

Department (through disease-specific Member newsletters or direct Member invitation by letter or

phone as the result of claims analysis information).

A Case Manager/Health Manager reviews the referral information and contacts the Member to

either schedule an office appointment with the Case Manager or to arrange to routinely

communicate with the Member telephonically. After the Member’s verbal and/or written consent

for participation is obtained, the Member is actively enrolled in the appropriate program. Members

may choose to “opt out” by contacting Piedmont’s Case Management Department.

Risk Stratification

Case Managers/Health Managers stratify active Members based on clinical criteria according to

low, moderate or high risk. For example, Members enrolled in the Congestive Heart Failure

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program are stratified according to the American College of Cardiology (ACC). Members with

diabetes are stratified using glycosolated hemoglobin (A1c) control and the presence of risk

factors.

Interventions

The degree of intervention is based on the Member’s risk stratification. For example, a Member

classified as low risk receives a minimum of one (1) program informational newsletter each year,

self-management education, a plan of care, and one or more follow-up office or phone

appointments. A Member with a high- risk stratification receives these interventions in addition to

more frequent office/phone visits and referrals for necessary specialty or case management

services.

Practitioner Decision Support

Case Managers/Health Managers are key to providing collaborative “real time” decision support to

PCPs. The Case Manager/Health Manager follow internally developed education Care Paths

(Algorithms) that complement the clinical guidelines. The education Care Paths (Algorithms)

provide a framework for self- management education, the recommended laboratory/diagnostic

studies, and targeted clinical goals.

The plan of care includes information regarding the Member’s self-management of their condition,

barriers, special considerations or exceptions, review of medical test results, management of co-

morbidities, collaborative goal-setting and problem-solving, medication review, plans for follow-

up, and preventive health monitoring. The plan of care is reviewed and discussed by the PCP

and/or SCP and the Case Manager/Health Manager in person, by phone, or through an electronic

medical record messaging process.

The involvement of the practitioner is integral in the design of program content for all Case

Management/Disease programs. Practitioner participation ensures program content is appropriate

for the actively practicing PCP. All PCPs are surveyed annually to elicit feedback regarding the

program(s).

Evaluation of Program Effectiveness

Program effectiveness is measured by conducting a pre-and post-analysis of pertinent clinical

measures, annual Member/practitioner program satisfaction surveys and pre- and post-comparisons

of services utilized by Members in the programs.

Practitioner’s Rights

Practitioners who care for Members have the right to:

• Obtain information regarding Case Management/Disease Management programs and

services in conjunction with Piedmont as outlined herein; and

• Obtain information regarding the qualifications of the Case Management staff; and

• Obtain information regarding how the Case Management staff facilitates

interventions via treatment plans for individual Members; and

22

• Know how to contact the Case Managers/Health Managers responsible for

managing and communicating with their patients; and

• Request the support of the Case Manager/Health Manager to make decisions

interactively with Members regarding their health care; and

• Receive courteous and respectful treatment from Case Management staff at all times; and

• File a Complaint when dissatisfied with any component of the Case Management/Health

Management programs by contacting the Case Management Department at (434) 947-

4463, toll free at (800) 400-7247, or the customer service team at the number listed on

your patient’s insurance card.

PROGRAM EXCEPTION PROCESS

Participating Providers may request coverage for items or services that are included under the

Member’s benefit package. Participating Providers may also request an exception for services or

items that exceed limits on the fee schedule if the limits are not based in statute or regulation.

These exceptions should be requested in advance of providing services. To request program

exceptions, Participating Providers must follow the Piedmont Prior Authorization process.

ADVANCE DIRECTIVES

The Patient Self-Determination Act of 1990, effective December 1, 1991, requires providers of

services and health maintenance organizations under the Medicare and Medicaid programs to

assure that individuals receiving services will be given an opportunity to participate in and

direct health care decisions affecting themselves and be informed of their right to have an

advance directive. An advance directive is a legal document through which a Member may

provide directions or express preferences concerning his or her medical care and/or to appoint

someone to act on his or her behalf. Advance directives are used when the Member is unable to

make or communicate decisions about his or her medical treatment. Advance directives are

prepared before any condition or circumstance occurs that causes the Member to be unable to

actively make decisions about his or her medical care.

In Virginia, there are two types of advance directives:

• Living will or healthcare instructions

• Appointment of a Health Care Power of Attorney

Providers are required to comply with federal and state laws regarding advance directives (also

known as health care power of attorney and living wills), as well as contractual requirements,

for adult Members. In addition, Piedmont requires that providers obtain and maintain advance

directive information in the Member’s medical record.

Requirements for providers include:

• Maintaining written policies that address a Member’s right to make decisions about

23

their medical care, including the right to refuse care

• Providing Members with written information about advance directives

• Documenting the Member’s advance directives or lack of one in his or her medical

record

• Communicating the Member’s wishes to attending staff in hospitals or other facilities

• Not discriminating against a Member or making treatment conditional on the basis of

his or her decision to have or not have an advance directive

• Providing staff education on issues related to advance directives

Piedmont provides information about advance directives to Members in the Member

Handbook, including the Member’s right to make decisions about their medical care, how to

obtain assistance in completing or filing a living will or health care power of attorney, and

general instructions.

For additional information or Complaints regarding noncompliance with advance directive

requirements, you can contact:

Virginia’s Office of the Attorney General

202 North Ninth Street

Richmond, Virginia 23219

Phone: (804) 786-2071.

24

REIMBURSEMENT & CLAIMS SUBMISSION

INTRODUCTION

This section of the Provider Manual has been created for use by all Plan practitioners/providers

and their staff to:

• Educate practitioners/providers about Piedmont’s claim submission requirements.

• Reduce the number of claim rejections and/or claim re-submissions because of initial

claim errors.

• Facilitate timely payment of claims.

GENERAL PAYMENT GUIDELINES

An important element in claims filing is the submission of current and accurate codes to reflect

the provider’s services. HIPAA-AS mandates the following code sets:

Claims filed with Piedmont Community Health Plan are subject to the following procedures:

• Verification that all required fields are completed on the CMS-1500 or UB-04 forms.

• Verification that all diagnosis and procedure codes are valid for the date of service.

• Verification for electronic claims against 837 edits.

• Verification of member eligibility for services during the period in which services were

provided.

• Verification that the services were provided by a participating provider or that an out-

of-network provider has received authorization to provide services to the eligible

member.

• Verification that an authorization or referral has been given for services that require

prior authorization or referral by the Plan.

Claims should be submitted in one of three formats:

• Electronic Claims Submission

• CMS 1500 Form

• UB04 or UB92 Form

For payment of Piedmont’s claims, Piedmont has adopted all guidelines and rules established

by CMS. Piedmont members may only be billed for their applicable copayments, coinsurance

and non-covered services.

Member Eligibility Verification

The Piedmont ID card is an identification card issue by Piedmont to each member. Prior to

rendering or billing for services, providers should verify each Member’s eligibility for benefits

through our online provider portal or call Piedmont’s Customer Service at 800-400-7247.

25

Provider Billing

Piedmont accepts both electronic and manual Claims submission. To assist us in processing

and paying Claims efficiently, accurately and timely, Piedmont encourages providers to submit

Claims electronically. To submit Claims electronically please use Payer ID 31441.

When to Submit Claims

Piedmont encourages providers to submit all claims as soon as possible after the date of service

to facilitate prompt payment and avoid delays that may result from expiration of timely filing

requirements.

Timely Submission of Claims

Unless otherwise stated in the Agreement, providers must submit clean claims to Piedmont

within 365 days from the date of service. The start date for determining the timely filing period

is the “from” date reported on a CMS-1500 and the “through” date used on the UB-04 for

institutional claims.

Unless prohibited by federal law or CMS, Piedmont may deny payment of any claim that fails

to meet Piedmont’s submission requirements for clean claims or failure to timely submit a

clean claim to Piedmont.

Any claim more than 365 days from the date of services will be denied as a Late Claim

Submission.

Claims Submissions

Paper claims MUST be submitted on one of the following standard Claim forms:

CMS-1500

• Required for all professional services and suppliers.

• Any professional services should be billed on CMS-1500 Claim forms, unless you

are contracted under a GLOBAL rate, in which case ‘professional services’ should

not be billed separately.

UB-04 or UB92

• Required for all facilities (e.g. hospitals) services.

Papers claims should be completed in their entirety, including but not limited to, the following

elements:

• The Plan member’s name and their relationship to the subscriber

• The beneficiary’s name, address, and insurance ID and indicated on the member’s

identification card

• The subscriber’s group name (if applicable)

• Information on other insurance or coverage

• The name, signature, place of service, address, billing address, and telephone number of

the provider performing the service

• The tax identification number, NPI number, for the provider performing the service

26

• The appropriate ICD-9 or ICD-10 codes at the highest specificity

• The standard CMS procedure or service codes with the appropriate modifiers

• The number of service units rendered

• The billed charges

• The name of the referring provider

• The dates of service

• The place of service

• The referral and/or authorization number

• The NDC for drug therapy

• Any job-related, auto-related, or other accident-related information, as applicable

Piedmont Community Health Plan claims should be mailed to:

Piedmont Community Health Plan

P.O. Box 14408

Cincinnati, OH 45250

Additional information can be found on the CMS website:

CMS Fact Sheet about UB-04

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNProducts/Downloads/837I-FormCMS-1450-ICN006926.pdf

CMS Fact Sheet about CMS-1500

http://www.cms.gov/outreach-and-education/medicare-learning-network-

mln/mlnproducts/downloads/form_cms-1500_fact_sheet.pdf

Follow these guidelines for faster paper claims processing:

• Do not submit hand-written forms

• Do not use script fonts

• Use a Bold font

• Do not use highlighter to emphasize any boxes

• Do not enter information outside the designated boxes

• Do not enter information in the wrong box or in the wrong order

• Do not include non-HIPAA-compliant information

• Accurately complete all required fields

Common Claims Filing Errors

Piedmont adheres to national and local payment policy requirements to ensure proper payment

of claims. Common types of errors that result in claim denials include:

• Billing/data entry errors

• Noncompliance with coverage policy

• Billing for services that are not medically necessary

• Incorrect Member ID number

• Invalid/missing Diagnosis code

• Past timely filing requirements

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• Incorrect provider number

• Missing, incorrect, or invalid modifier

• Invalid/missing Healthcare Common Procedure Coding Systems (HCPCS) code

• Missing or incorrect quantity/units

Claims are rejected due to billing errors are typically rejected for incorrect procedure codes,

etc. Rejected claims are not processed claims and the provider will receive a letter that the

claim was rejected. There are NO APPEAL rights – the claim must be corrected and

resubmitted for further consideration.

In some cases, additional documentation may be required for the claim to complete

adjudication. After Piedmont receives the additional information, the claim can be adjusted or

corrected.

Claims Denied in Error

The provider must follow-up with Piedmont within 365 days of the date of service for the

claims the provider suspects have been denied in error. If after researching the claim,

Piedmont discovers that the claim was denied in error the provider is entitled to payment.

Worker’s Compensation/Accident Related Claims

Any claim with an injury diagnosis code for a patient will be reviewed. Piedmont

communicates with the Member to determine if the injury is work-related or for some plans if a

third party is involved for Subrogation. Piedmont will automatically send a letter to the

Member requesting information about the injury.

Corrected Claims, Requests for Reconsideration or Claim Disputes

All requests for corrected claims, reconsiderations or claim disputes must be received within 60

days from the date of explanation of payment or denial is issued. Requests received after 60

days from the date of explanation of payment or denial notification will be denied for untimely

filing.

National Provider Identifier (NPI)

All claims submitted to Piedmont must include individual and Group Practice NPI number and

taxonomy codes. Claims received without an NPI and taxonomy code will be rejected or

denied. More information on NPI requirements, including the Health Insurance Portability and

Accountability Act of 1996’s (HIPAA) NPI Final Rule Administrative Simplification, is

available on the CMS website at http://www.cms.gov.

Coordination of Benefits

Piedmont shall coordinate payment of Covered Services in accordance with the terms of a

member’s benefit plan, applicable state and federal laws, and CMS guidance. Providers shall

bill primary insurers for items and services they provide to a member before they submit claims

for the same items or services to Piedmont. Any balance due after receipt of payment from the

primary payer should be submitted to Piedmont for consideration, and the claims must include

information verifying the payment amount received from the primary insurer.

28

Encounter Data – Piedmont’s Medicare Advantage

Piedmont must submit to CMS all data necessary to characterize the context and purpose of

each encounter between a Medicare enrollee and a provider, supplier, physician, or other

practitioner.

Information about physician services must be submitted by Piedmont for all the services

provided by network and non-network physicians and non-physician practitioners.

The extent of the data must account for:

• Services covered under the original Medicare program.

• Medicare-covered services for which Medicare is not the primary payer and

additional or supplemental benefits that Piedmont may provide.

The data must account separately for each provider, supplier, physician or other health care

practitioner that would be permitted to bill separately under the Medicare fee-for-service

program, even if they participate jointly in the same encounter.

Data requirements must also:

• Conform to the requirements for equivalent data for Medicare fee-for-service

when appropriate, and to all relevant national standards.

• Be submitted electronically by Piedmont to the appropriate CMS contractor.

Piedmont and its providers and practitioners will be required to submit medical records for the

validation of encounter data as prescribed by CMS. CMS will use the data obtained under this

section to determine the risk adjustment factor that it applies to annual capitation rates and any

other purposes. Please refer to your provider/practitioner services agreement.

Encounter data shall include all information necessary for Piedmont to submit data to CMS as

set forth in 42 CFR Section 422.257. If the provider fails to submit encounter data accurately,

completely and truthfully, in the format described in 42 CFR Section 422.257, then this will

result in denials and/or delays in payment of the provider’s claims.

Each provider has contractually agreed to certify the accuracy, completeness, and truthfulness

of the provider’s generated encounter data that Piedmont is obligated to submit to CMS. No

later than 30 days after the beginning of every fiscal year while the Medicare Advantage

participation is in effect, the provider agrees, upon request, to give Piedmont a certification in

writing, in a format that Piedmont specifies, that certifies to the accuracy, completeness, and

truthfulness of the provider’s encounter data submitted to the plan during the specific period.

Data Reporting Submissions

Each provider agrees to provide all information necessary to meet its data reporting and

submission obligations to CMS including, but not limited to, data necessary to characterize the

context and purpose of each encounter between a Medicare Advantage enrollee and the

provider, and data necessary for Piedmont to meet its reporting obligations under 42 CFR

Section 422.516.

Federal Funds

29

Piedmont has a contract with CMS to perform activities as a Medicare Advantage (MA)

organization. In performing its duties as an MA, Piedmont receives Federal payments and, as

such, Piedmont agrees to comply, and must ensure that all related entities, contractors, and

subcontractors paid by Piedmont to fulfill Piedmont’s obligations under its MA contract with

CMS agree to comply with all Federal laws applicable to those entities receiving Federal funds.

The payments providers receive from Piedmont under this agreement for services rendered to

Piedmont’s Medicare Advantage covered individuals are, in whole or in part, from Federal

funds. Thus, each provider, as a recipient of said Federal funds, agrees to comply with the

following:

• Title VI of the Civil Rights Act of 1964 as implemented by regulations at 45

CFR part 84

• The Age Discrimination Act of 1975 as implemented by regulations at 45 CFR

part 91

• The Americans with Disabilities Act

• Rehabilitation Act of 1973

• Other laws applicable to recipients of Federal funds, and

• All other applicable laws and rules.

Prompt Payment by Piedmont

Receipt of claims by non-contracted providers will be considered a “clean claim” if it contains

all necessary information for the purposes of encounter data requirements and complies with

the requirement for a clean claim under fee-for-service Medicare. Piedmont is bound to adhere

to the following prompt payment provisions for non-contracted providers:

• Pay 95 percent of clean claims within 30 days of receipt

• Pay interest on clean claims not paid within 30 days

• All other claims must be approved or denied within 60 calendar days from date

of receipt.

All contracted providers must include a prompt payment provision in their contract, the terms

of which are developed and agreed to by Piedmont and the provider.

Claims with incomplete or inaccurate data elements will be returned with written notification

of how to correct and resubmit the claim. Claims that need additional information in order to

be reprocessed will be suspended and a written request for the specific information will be sent

to the provider. If the requested information is not received within the specified timeframe, the

claim will be closed and the provider will be notified.

Piedmont may not pay, directly or indirectly on any basis (other than emergency or urgent

services), claims to a physician or other practitioner who has filed with the Medicare carrier an

affidavit promising to furnish Medicare-covered services to Medicare beneficiaries only

through private contracts.

Providers who would like to review any of the sections referenced in their entirety, may access

the CMS website at www.cms.gov. Please review this site periodically to obtain the most

current CMS policy and procedures as released.

30

CREDENTIALING

Credentialing Scope

A. Professional Practitioners:

1. Practitioner Types: Piedmont credentials the following health care practitioners, when

an independent relationship exists between Piedmont and the Practitioner, or the

individual Practitioner is listed individually in Piedmont’s provider network directory;

and exclusions in section 2 (see below) do not apply:

• Medical Doctors (MD)

• Doctors of Osteopathic Medicine (DO)

• Doctors of Podiatry

• Chiropractors

• Optometrists providing Health Services covered under the Health Benefits

Plan

• Oral and Maxillofacial surgeons

• Psychologists who are state certified or licensed and have doctoral or master’s

level training

• Clinical social workers who are state certified or state licensed and have

master’s level training

• Psychiatric nurse practitioners who are nationally or state certified or state

licensed or behavioral nurse specialists with master’s level training

• Other behavioral health care specialists who are licensed, certified or registered

by the state to practice independently

• Telemedicine practitioners who have an independent relationship with

Piedmont and who provide treatment services under the Health Benefits Plan

• Medical therapists (e.g., physical therapists, speech therapists, and

occupational therapists)

• Licensed Genetic Counselors who are licensed by the state to practice

independently

• Audiologists who are licensed by the state to practice independently

• Acupuncturists (non-MD/DO) who are licensed, certified or registered by the

state to practice independently

• Certified nurse midwives

2. Practitioners with whom we have a contractual relationship do not require

credentialing when the Practitioner:

• Practices exclusively in an inpatient setting and provides care for Piedmont

Covered Individuals only because Covered Individuals are directed to the

hospital or another inpatient setting; OR

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• Practices exclusively in free-standing facilities and provides care for Piedmont

Covered Individuals only because Covered Individuals are directed to the

facility.

Examples of this type of Practitioner include, but are not limited to:

o Pathologists

o Radiologists

o Anesthesiologists

o Neonatologists

o Emergency Room Physicians

o Urgent Care Center Physicians o Urgent Care Center mid-level providers (e.g. nurse practitioners,

physician assistants)

o Hospitalists

o Pediatric Intensive Care Specialists

o Other Intensive Care Specialists

3. The following behavioral health practitioners are not subject to professional conduct

and competence review under Piedmont’s credentialing program, but are subject to a

certification requirement process including verification of licensure by the applicable

state licensing board to independently provide behavioral health services and/or

compliance with regulatory or state/federal contract requirements for the provision of

services:

• Certified Behavioral Analysts

• Certified Addiction Counselors

• Substance Abuse Practitioners

Note: an individual who is contracted and practices in the office setting must be

credentialed when that practitioner meets criteria in section 2 of this Credentialing

Policy, above.

B. Health Delivery Organizations (HDOs):

1. Piedmont credentials the following Health Delivery Organizations:

• Hospitals

• Home Health Agencies

• Skilled Nursing Facilities

• Ambulatory Surgical Centers

• Behavioral Health Facilities providing mental health and/or substance abuse

treatment in inpatient, residential or ambulatory settings, including:

o Adult Family Care/Foster Care Homes

o Ambulatory Detox

o Community Mental Health Centers (CMHC)

o Crisis Stabilization Units

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o Intensive Family Intervention Services

o Intensive Outpatient – Mental Health and/or Substance Abuse

o Methadone Maintenance Clinics

o Outpatient Mental Health Clinics

o Outpatient Substance Abuse Clinics

o Partial Hospitalization – Mental Health and/or Substance Abuse o Residential Treatment Centers (RTC) – Psychiatric and/or Substance

Abuse

• Birthing Centers

• Convenient Care Centers/Retail Health Clinics/Walk-In Clinics

• Intermediate Care Facilities

• Urgent Care Centers

• Federally Qualified Health Centers (FQHC)

• Home Infusion Therapy when not associated with another currently

credentialed HDO

• Rural Health Clinics

2. The following Health Delivery Organizations are not subject to professional conduct

and competence review under Piedmont’s credentialing program, but are subject to a

certification requirement process including verification of licensure by the applicable

state licensing agency and/or compliance with regulatory or state/federal contract

requirements for the provision of services:

• Clinical laboratories (a CMS-issued CLIA certificate or a hospital based

exemption from CLIA)

• End Stage Renal Disease (ESRD) service providers (dialysis facilities)

• Portable x-ray Suppliers

• Home Infusion Therapy when associated with another currently credentialed

HDO

Credentials Committee

The decision to accept, retain, deny or terminate a practitioner’s participation in a Network or

Plan Program is conducted by a peer review body, known as Piedmont’s Medical Affairs

Committee.

The Medical Affairs Committee will meet at least once every forty-five (45) calendar days. The

presence of a majority of voting of the Medical Affairs Committee members constitutes a

quorum. The chair must be a state or regional lead medical director, or an Piedmont medical

director of business also represented by the chair. The Medical Affairs Committee will include at

least five, but no more than ten external physicians representing multiple medical specialties (in

general, the following specialties or practice-types should be represented: pediatrics,

obstetrics/gynecology, adult medicine (family medicine or internal medicine); surgery; behavioral

health, with the option of using other specialties when needed as determined by the medical

director). At least two of the physician committee members must be credentialed for each line of

business (e.g. Commercial, Medicare) offered within the geographic purview of the Medical

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Affairs Committee. The Medical Affairs Committee will serve as a voting member(s) and

provide support to the credentialing/re-credentialing process as needed.

The Medical Affairs Committee will access various specialists for consultation, as needed to

complete the review of a practitioner’s credentials. A committee member will disclose and

abstain from voting on a practitioner if the committee member (i) believes there is a conflict of

interest, such as direct economic competition with the practitioner; or (ii) feels his or her

judgment might otherwise be compromised. A committee member will also disclose if he or

she has been professionally involved with the practitioner. Determinations to deny an

applicant’s participation, or terminate a practitioner from participation in one or more

Networks or Plan Programs, require a majority vote of the voting members of the Medical

Affairs Committee attendance, the majority of whom are Network practitioners.

During the credentialing process, all information that is obtained is highly confidential. All

Medical Affairs Committee meeting minutes and practitioner files are stored in highly secured

electronic data system and can only be seen by appropriate Credentialing staff, medical

directors, and Medical Affairs Committee members.

Documents in these files may not be reproduced or distributed, except for confidential peer

review and credentialing purposes; and peer review protected information will not be shared

externally.

Practitioners and HDOs are notified that they have the right to review information submitted to

support their credentialing applications. This right includes access to information obtained from

any outside sources with the exception of references, recommendations or other peer review

protected information. Providers are given written notification of these rights in

communications from Piedmont’s credentialing verification office, which initiates the

credentialing process. In the event that credentialing information cannot be verified, or if there

is a discrepancy in the credentialing information obtained, the credentialing verification office

will contact the practitioner or HDO within thirty (30) calendar days of the identification of the

issue. This communication will specifically notify the practitioner or HDO of the right to

correct erroneous information or provide additional details regarding the issue in question. This

notification will also include the specific process for submission of this additional information,

including where it should be sent. Depending on the nature of the issue in question, this

communication may occur verbally or in writing. If the communication is verbal, written

confirmation will be sent at a later date. All communication on the issue(s) in question,

including copies of the correspondence or a detailed record of phone calls, will be clearly

documented in the practitioner’s credentials file. The practitioner or HDO will be given no less

than fourteen (14) calendar days in which to provide additional information. Upon request,

applicant will be provided with the status of his or her credentialing application. Written

notification of this right may be included in a variety of communications from Piedmont which

includes the letter which initiates the credentialing process, the provider web site or Provider

Manual. When such requests are received, providers will be notified whether the credentialing

application has been received, how far in the process it has progressed and a reasonable date

for completion and notification. All such requests will be responded to verbally unless the

provider requests a written response.

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Piedmont may request and will accept additional information from the applicant to correct or

explain incomplete, inaccurate, or conflicting credentialing information. The Medical Affairs

Committee will review the information and rationale presented by the applicant to determine if

a material omission has occurred or if other credentialing criteria are met.

Nondiscrimination Policy

Piedmont will not discriminate against any applicant for participation in its Networks or Plan

Programs on the basis of race, gender, color, creed, religion, national origin, ancestry, sexual

orientation, age, veteran, or marital status or any unlawful basis not specifically mentioned

herein. Additionally, Piedmont will not discriminate against any applicant on the basis of the

risk of population they serve or against those who specialize in the treatment of costly

conditions. Other than gender and language capabilities that are provided to the Covered

Individuals to meet their needs and preferences, this information is not required in the

credentialing and re-credentialing process. Determinations as to which practitioners/HDOs

require additional individual review by the Medical Affairs Committee are made according to

predetermined criteria related to professional conduct and competence as outlined in Piedmont

Credentialing Program Standards. Medical Affairs Committee decisions are based on issues of

professional conduct and competence as reported and verified through the credentialing

process.

Initial Credentialing

Each practitioner or HDO must complete a standard application form when applying for initial

participation in one or more of Piedmont’s Networks or Plan Programs. This application may

be a state mandated form or a standard form created by or deemed acceptable by Piedmont. For

practitioners, the Council for Affordable Quality Healthcare (CAQH), a Universal

Credentialing Datasource is utilized. CAQH built the first national provider credentialing

database system, which is designed to eliminate the duplicate collection and updating of

provider information for health plans, hospitals and practitioners. To learn more about CAQH,

visit their web site at www.caqh.org.

Piedmont will verify those elements related to an applicants’ legal authority to practice,

relevant training, experience and competency from the primary source, where applicable,

during the credentialing process. All verifications must be current and verified within the one

hundred eighty (180) calendar day period prior to the Medical Affairs Committee making its

credentialing recommendation or as otherwise required by applicable accreditation standards.

During the credentialing process, Piedmont will review verification of the credentialing data as

described in the following tables unless otherwise required by regulatory or accrediting bodies.

These tables represent minimum requirements.

A. Practitioners

Verification Element

License to practice in the state(s) in which the practitioner will be

treating Covered Individuals.

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Hospital admitting privileges at a TJC, NIAHO or AOA accredited

hospital, or a Network hospital previously approved by the committee.

DEA/CDS and state controlled substance registrations

a. The DEA/CDS registration must be valid in the state(s) in

which practitioner will be treating Covered Individuals.

Practitioners who see Covered Individuals in more than one

state must have a DEA/CDS registration for each state.

Malpractice insurance

Malpractice claims history

Board certification or highest level of medical training or education

Work history

State or Federal license sanctions or limitations

Medicare, Medicaid or FEHBP sanctions

National Practitioner Data Bank report

State Medicaid Exclusion Listing, if applicable

B. HDOs

Verification Element

Accreditation, if applicable

License to practice, if applicable

Malpractice insurance

Medicare certification, if applicable

Department of Health Survey Results or recognized accrediting

organization certification

License sanctions or limitations, if applicable

Medicare, Medicaid or FEHBP sanctions

Recredentialing

The recredentialing process incorporates re-verification and the identification of changes in the

practitioner’s or HDO’s licensure, sanctions, certification, health status and/or performance

information (including, but not limited to, malpractice experience, hospital privilege or other

actions) that may reflect on the practitioner’s or HDO’s professional conduct and competence.

This information is reviewed in order to assess whether practitioners and HDOs continue to

meet Piedmont’s credentialing standards.

During the recredentialing process, Piedmont will review verification of the credentialing data

as described in the tables under Initial Credentialing unless otherwise required by regulatory or

accrediting bodies. These tables represent minimum requirements.

All applicable practitioners and HDOs in the Network within the scope of Piedmont

Credentialing Program are required to be recredentialed every three (3) years unless otherwise

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required by contract or state regulations.

Health Delivery Organizations

New HDO applicants will submit a standardized application to Piedmont for review. If the

candidate meets Piedmont’s screening criteria, the credentialing process will commence. To

assess whether Network HDOs, within the scope of the Credentialing Program, meet appropriate

standards of professional conduct and competence, they are subject to credentialing and

recredentialing programs. In addition to the licensure and other eligibility criteria for HDOs, as

described in detail in Piedmont’s Credentialing Program Standards, all Network HDOs are

required to maintain accreditation by an appropriate, recognized accrediting body or, in the

absence of such accreditation, Piedmont may evaluate the most recent site survey by Medicare,

the appropriate state oversight agency, or a site survey performed by a designated independent

external entity within the past 36 months for that HDO.

Recredentialing of HDOs occurs every three (3) years unless otherwise required by regulatory or

accrediting bodies. Each HDO applying for continuing participation in Networks or Plan

Programs must submit all required supporting documentation.

On request, HDOs will be provided with the status of their credentialing application. Piedmont

may request, and will accept, additional information from the HDO to correct incomplete,

inaccurate, or conflicting credentialing information. The Medical Affairs Committee will review

this information and the rationale behind it, as presented by the HDO, and determine if a material

omission has occurred or if other credentialing criteria are met.

Ongoing Sanction Monitoring

To support certain credentialing standards between the recredentialing cycles, Piedmont has

established an ongoing monitoring program. Credentialing performs ongoing monitoring to help

ensure continued compliance with credentialing standards and to assess for occurrences that may

reflect issues of substandard professional conduct and competence. To achieve this, the

credentialing department will review periodic listings/reports within thirty (30) calendar days of

the time they are made available from the various sources including, but not limited to, the

following:

• Office of the Inspector General (OIG)

• Federal Medicare/Medicaid Reports

• Office of Personnel Management (OPM)

• State licensing Boards/Agencies

• Covered Individual/Customer Services Departments

• Clinical Quality Management Department (including data regarding complaints

of both a clinical and non-clinical nature, reports of adverse clinical events and

outcomes, and satisfaction data, as available)

• Other internal Piedmont Departments

• Any other verified information received from appropriate sources

When a practitioner or HDO within the scope of credentialing has been identified by these

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sources, criteria will be used to assess the appropriate response including, but not limited to:

review by the Medical Affairs Committee of Piedmont, review by the Piedmont Medical

Director, referral to the Medical Affairs Committee, or termination. Piedmont’s credentialing

departments will report practitioners or HDOs to the appropriate authorities as required by law.

Appeals Process

Piedmont has established policies for monitoring and re-credentialing practitioners and HDOs

who seek continued participation in one or more of Piedmont’s Networks or Plan Programs.

Information reviewed during this activity may indicate that the professional conduct and

competence standards are no longer being met, and Piedmont may wish to terminate practitioners

or HDOs. Piedmont also seeks to treat Network practitioners and HDOs, as well as those

applying for participation, fairly and thus provides practitioners and HDOs with a process to

appeal determinations terminating participation in Piedmont's Networks for professional

competence and conduct reasons, or which would otherwise result in a report to the National

Practitioner Data Bank (NPDB). Additionally, Piedmont will permit practitioners and HDOs

who have been refused initial participation the opportunity to correct any errors or omissions

which may have led to such denial (informal/reconsideration only). It is the intent of Piedmont to

give practitioners and HDOs the opportunity to contest a termination of the practitioner’s or

HDO’s participation in one or more of Piedmont’s Networks or Plan Programs and those denials

of request for initial participation which are reported to the NPDB that were based on

professional competence and conduct considerations. Immediate terminations may be imposed

due to the practitioner’s or HDO’s suspension or loss of licensure, criminal conviction, or

Piedmont’s determination that the practitioner’s or HDO’s continued participation poses an

imminent risk of harm to Covered Individuals. A practitioner/HDO whose license has been

suspended or revoked has no right to informal review/reconsideration or formal appeal.

Reporting Requirements

When Piedmont takes a professional review action with respect to a practitioner’s or HDO’s

participation in one or more of its Networks or Plan Programs, Piedmont may have an obligation

to report such to the NPDB. Once Piedmont receives a verification of the NPDB report, the

verification report will be sent to the state licensing board. The credentialing staff will comply

with all state and federal regulations in regard to the reporting of adverse determinations relating

to professional conduct and competence. These reports will be made to the appropriate, legally

designated agencies. In the event that the procedures set forth for reporting reportable adverse

actions conflict with the process set forth in the current NPDB Guidebook, the process set forth

in the NPDB Guidebook will govern.

I. Eligibility Criteria

Health care practitioners:

Initial applicants must meet the following criteria to be considered for participation:

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A. Must not be currently federally sanctioned, debarred or excluded from participation in any

of the following programs: Medicare, Medicaid or FEHBP; and.

B. Possess a current, valid, unencumbered, unrestricted, and non-probationary license in the

state(s) where he/she provides services to Covered Individuals; and

C. Possess a current, valid, and unrestricted Drug Enforcement Agency (DEA) and/or

Controlled Dangerous Substances (CDS) registration for prescribing controlled substances,

if applicable to his/her specialty in which he/she will treat Covered Individuals; the

DEA/CDS registration must be valid in the state(s) in which the practitioner will be treating

Covered Individuals. Practitioners who see Covered Individuals in more than one state

must have a DEA/CDS registration for each state.

Initial applications should meet the following criteria in order to be considered for

participation, with exceptions reviewed and approved by the CC:

A. For MDs, DOs, DPMs, and oral and maxillofacial surgeons, the applicant must have

current, in force board certification (as defined by the American Board of Medical

Specialties (ABMS), American Osteopathic Association (AOA), Royal College of

Physicians and Surgeons of Canada (RCPSC), College of Family Physicians of Canada

(CFPC), American Board of Podiatric Surgery (ABPS), American Board of Podiatric

Medicine (ABPM), or American Board of Oral and Maxillofacial Surgery (ABOMS))

in the clinical discipline for which they are applying.

B. Individuals will be granted five years or a period of time consistent with ABMS board

eligibility time limits, whatever is greater, after completion of their residency or

fellowship training program to meet the board certification requirement.

C. Individuals with board certification from the American Board of Podiatric Medicine will

be granted five years after the completion of their residency to meet this requirement.

Individuals with board certification from the American Board of Foot and Ankle

Surgery will be granted seven years after completion of their residency to meet this

requirement.

D. Individuals no longer eligible for board certification are not eligible for continued

exception to this requirement.

1. As alternatives, MDs and DOs meeting any one of the following criteria will be

viewed as meeting the education, training and certification requirement:

a. Previous board certification (as defined by one of the following: ABMS,

AOA, RCPSC, or CFPC) in the clinical specialty or subspecialty for

which they are applying which has now expired AND a minimum of ten

(10) consecutive years of clinical practice. OR

b. Training which met the requirements in place at the time it was

completed in a specialty field prior to the availability of board

certifications in that clinical specialty or subspecialty. OR

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c. Specialized practice expertise as evidenced by publication in nationally

accepted peer review literature and/or recognized as a leader in the

science of their specialty AND a faculty appointment of Assistant

Professor or higher at an academic medical center and teaching Facility

in Piedmont’s Network AND the applicant’s professional activities are

spent at that institution at least fifty percent (50%) of the time.

2. Practitioners meeting one of these three (3) alternative criteria (a, b, c) will be

viewed as meeting all Piedmont education, training and certification criteria and

will not be required to undergo additional review or individual presentation to

the CC. These alternatives are subject to Piedmont review and approval. Reports

submitted by delegate to Piedmont must contain sufficient documentation to

support the above alternatives, as determined by Piedmont.

E. For MDs and DOs, the applicant must have unrestricted hospital privileges at The Joint

Commission (TJC), National Integrated Accreditation for Healthcare Organizations

(NIAHO), an AOA accredited hospital, or a Network hospital previously approved by

the committee. Some clinical disciplines may function exclusively in the outpatient

setting, and the CC may at its discretion deem hospital privileges not relevant to these

specialties. Also, the organization of an increasing number of physician practice settings

in selected fields is such that individual physicians may practice solely in either an

outpatient or an inpatient setting. The CC will evaluate applications from practitioners

in such practices without regard to hospital privileges. The expectation of these

physicians would be that there is an appropriate referral arrangement with a Network

practitioner to provide inpatient care.

II. Criteria for Selecting Practitioners

A. New Applicants (Credentialing)

1. Submission of a complete application and required attachments that must not

contain intentional misrepresentations;

2. Application attestation signed date within one hundred eighty (180)

calendar days of the date of submission to the CC for a vote;

3. Primary source verifications within acceptable timeframes of the date of

submission to the CC for a vote, as deemed by appropriate accrediting

agencies;

4. No evidence of potential material omission(s) on application;

5. Current, valid, unrestricted license to practice in each state in which the

practitioner would provide care to Covered Individuals;

6. No current license action;

7. No history of licensing board action in any state;

8. No current federal sanction and no history of federal sanctions (per

System for Award Management (SAM), OIG and OPM report nor on

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NPDB report);

9. Possess a current, valid, and unrestricted DEA/CDS registration for

prescribing controlled substances, if applicable to his/her specialty in which

he/she will treat Covered Individuals. The DEA/CDS registration must be

valid in the state(s) in which the practitioner will be treating Covered

Individuals. Practitioners who treat Covered Individuals in more than one state

must have a valid DEA/CDS registration for each applicable state.

Initial applicants who have NO DEA/CDS registration will be viewed as not

meeting criteria and the credentialing process will not proceed. However, if the

applicant can provide evidence that he/she has applied for a DEA/CDS

registration the credentialing process may proceed if all of the following are

met:

a. It can be verified that this application is pending.

b. The applicant has made an arrangement for an alternative practitioner

to prescribe controlled substances until the additional DEA/CDS

registration is obtained.

c. The applicant agrees to notify Piedmont upon receipt of the required

DEA/CDS registration.

d. Piedmont will verify the appropriate DEA/CDS registration via

standard sources

i. The applicant agrees that failure to provide the appropriate

DEA/CDS registration within a ninety (90) calendar day

timeframe will result in termination from the Network.

ii. Initial applicants who possess a DEA/CDS registration in a state

other than the state in which they will be treating Covered

Individuals will be notified of the need to obtain the additional

DEA/CDS registration. If the applicant has applied for additional

DEA/CDS registration, the credentialing process may proceed if

ALL the following criteria are met:

(a) It can be verified that this application is pending and,

(b) The applicant has made an arrangement for an alternative

practitioner to prescribe controlled substances until the

additional DEA/CDS registration is obtained,

(c) The applicant agrees to notify Piedmont upon receipt of the

required DEA/CDS registration,

(d) Piedmont will verify the appropriate DEA/CDS registration

via standard sources; applicant agrees that failure to

provide the appropriate DEA/CDS registration within a

ninety (90) calendar day timeframe will result in

termination from the Network,

AND

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(e) Must not be currently federally sanctioned, debarred or

excluded from participation in any of the following

programs: Medicare, Medicaid or FEHBP.

10. No current hospital membership or privilege restrictions and no history of

hospital membership or privileges restrictions;

11. No history of or current use of illegal drugs or history of or current alcoholism;

12. No impairment or other condition which would negatively impact the ability to

perform the essential functions in their professional field.

13. No gap in work history greater than six (6) months in the past five (5) years

with the exception of those gaps related to parental leave or immigration

where twelve (12) month gaps will be acceptable. Other gaps in work history

of six to twenty-four (6 to 24) months will be reviewed by the Chair of the CC

and may be presented to the CC if the gap raises concerns of future

substandard professional conduct and competence. In the absence of this

concern the Chair of the CC may approve work history gaps of up to two (2)

years.

14. No history of criminal/felony convictions or a plea of no contest;

15. A minimum of the past ten (10) years of malpractice case history is reviewed.

16. Meets Credentialing Standards for education/training for the specialty(ies) in

which practitioner wants to be listed in Piedmont’s Provider Directory as

designated on the application. This includes board certification requirements

or alternative criteria for MDs and DOs and board certification criteria for

DPMs, and oral and maxillofacial surgeons;

17. No involuntary terminations from an HMO or PPO;

18. No “yes” answers to attestation/disclosure questions on the application form

with the exception of the following:

a. investment or business interest in ancillary services, equipment or

supplies;

b. voluntary resignation from a hospital or organization related to practice

relocation or facility utilization;

c. voluntary surrender of state license related to relocation or nonuse of said

license;

d. a NPDB report of a malpractice settlement or any report of a malpractice

settlement that does not meet the threshold criteria.

e. non-renewal of malpractice coverage or change in malpractice carrier

related to changes in the carrier’s business practices (no longer offering

coverage in a state or no longer in business);

f. previous failure of a certification exam by a practitioner who is currently

board certified or who remains in the five (5) year post residency training

window;

g. actions taken by a hospital against a practitioner’s privileges related

42

solely to the failure to complete medical records in a timely fashion;

h. history of a licensing board, hospital or other professional entity

investigation that was closed without any action or sanction.

Note: the CC will individually review any practitioner that does not meet one or

more of the criteria required for initial applicants.

Practitioners who meet all participation criteria for initial or continued participation

and whose credentials have been satisfactorily verified by the Credentialing

department may be approved by the Chair of the CC after review of the applicable

credentialing or recredentialing information. This information may be in summary

form and must include, at a minimum, practitioner’s name and specialty.

B. Currently Participating Applicants (Recredentialing)

1. Submission of complete re-credentialing application and required attachments that

must not contain intentional misrepresentations;

2. Re-credentialing application signed date within one hundred eighty (180) calendar

days of the date of submission to the CC for a vote;

3. Primary source verifications within acceptable timeframes of the date of submission

to the CC for a vote, as deemed by appropriate accrediting agencies;

4. No evidence of potential material omission(s) on re-credentialing application;

5. Must not be currently federally sanctioned, debarred or excluded from participation

in any of the following programs: Medicare, Medicaid or FEHBP. If, once a

Practitioner participates in Piedmont’s programs or provider Network(s), federal

sanction, debarment or exclusion from the Medicare, Medicaid or FEHBP programs

occurs, at the time of identification, the Practitioner will become immediately

ineligible for participation in the applicable government programs or provider

Network(s) as well as Piedmont’s other credentialed provider Network(s).

6. Current, valid, unrestricted license to practice in each state in which the practitioner

provides care to Covered Individuals;

7. *No current license probation;

8. *License is unencumbered;

9. No new history of licensing board reprimand since prior credentialing review;

10. *No current federal sanction and no new (since prior credentialing review) history

of federal sanctions (per SAM, OIG and OPM Reports or on NPDB report);

11. Current DEA/CDS registration and/or state controlled substance certification

without new (since prior credentialing review) history of or current restrictions;

12. No current hospital membership or privilege restrictions and no new (since prior

credentialing review) history of hospital membership or privilege restrictions; OR

for practitioners in a specialty defined as requiring hospital privileges who practice

solely in the outpatient setting there exists a defined referral relationship with a

Network practitioner of similar specialty at a Network HDO who provides inpatient

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care to Covered Individuals needing hospitalization;

13. No new (since previous credentialing review) history of or current use of illegal

drugs or alcoholism;

14. No impairment or other condition which would negatively impact the ability to

perform the essential functions in their professional field;

15. No new (since previous credentialing review) history of criminal/felony convictions,

including a plea of no contest;

16. Malpractice case history reviewed since the last CC review. If no new cases are

identified since last review, malpractice history will be reviewed as meeting criteria.

If new malpractice history is present, then a minimum of last five (5) years of

malpractice history is evaluated and criteria consistent with initial credentialing is

used.

17. No new (since previous credentialing review) involuntary terminations from an

HMO or PPO;

18. No new (since previous credentialing review) “yes” answers on

attestation/disclosure questions with exceptions of the following:

a. investment or business interest in ancillary services, equipment or supplies;

b. voluntary resignation from a hospital or organization related to practice

relocation or facility utilization;

c. voluntary surrender of state license related to relocation or nonuse of said

license;

d. an NPDB report of a malpractice settlement or any report of a malpractice

settlement that does not meet the threshold criteria;

e. nonrenewal of malpractice coverage or change in malpractice carrier related

to changes in the carrier’s business practices (no longer offering coverage in

a state or no longer in business);

f. previous failure of a certification exam by a practitioner who is currently

board certified or who remains in the five (5) year post residency training

window;

g. actions taken by a hospital against a practitioner’s privileges related solely to

the failure to complete medical records in a timely fashion;

h. history of a licensing board, hospital or other professional entity

investigation that was closed without any action or sanction.

19. No QI data or other performance data including complaints above the set threshold.

20. Recredentialed at least every three (3) years to assess the practitioner’s continued

compliance with Piedmont standards.

*It is expected that these findings will be discovered for currently credentialed

Network practitioners and HDOs through ongoing sanction monitoring.

Network practitioners and HDOs with such findings will be individually reviewed

and considered by the CC at the time the findings are identified.

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Note: the CC will individually review any credentialed Network practitioners and

HDOs that do not meet one or more of the criteria for recredentialing.

C. Additional Participation Criteria and Exceptions for Behavioral Health Practitioners (Non-

Physician) Credentialing

1. Licensed Clinical Social Workers (LCSW) or other master level social work license

type:

a. Master or doctoral degree in social work with emphasis in clinical social work

from a program accredited by the Council on Social Work Education (CSWE) or

the Canadian Association on Social Work Education (CASWE).

b. Program must have been accredited within three (3) years of the time the

practitioner graduated.

c. Full accreditation is required, candidacy programs will not be considered.

d. If master’s level degree does not meet criteria and practitioner obtained PhD

training as a clinical psychologist, but is not licensed as such, the practitioner

can be reviewed. To meet the criteria, the doctoral program must be accredited

by the American Psychological Association (APA) or be regionally accredited

by the Council for Higher Education Accreditation (CHEA). In addition, a

doctor of social work from an institution with at least regional accreditation

from the CHEA will be viewed as acceptable.

2. Licensed professional counselor (LPC) and marriage and family therapist (MFT) or

other master level license type:

a. Master’s or doctoral degree in counseling, marital and family therapy,

psychology, counseling psychology, counseling with an emphasis in

marriage, family and child counseling or an allied mental field. Master or

doctoral degrees in education are acceptable with one of the fields of study

above.

b. Master or doctoral degrees in divinity do not meet criteria as a related field

of study.

c. Graduate school must be accredited by one of the Regional Institutional

Accrediting Bodies and may be verified from the Accredited Institutions of

Post-Secondary Education, APA, Council for Accreditation of Counseling

and Related Educational Programs (CACREP), or Commission on

Accreditation for Marriage and Family Therapy Education (COAMFTE)

listings. The institution must have been accredited within three (3) years of

the time the practitioner graduated.

d. Practitioners with PhD training as a clinical psychologist can be reviewed.

To meet criteria this doctoral program must either be accredited by the APA

or be regionally accredited by the CHEA. A Practitioner with a doctoral

degree in one of the fields of study noted will be viewed as acceptable if the

institution granting the degree has regional accreditation from the CHEA

and;

45

e. Licensure to practice independently.

3. Clinical nurse specialist/psychiatric and mental health nurse practitioner:

a. Master’s degree in nursing with specialization in adult or child/adolescent

psychiatric and mental health nursing. Graduate school must be accredited

from an institution accredited by one of the Regional Institutional

Accrediting Bodies within three (3) years of the time of the practitioner’s

graduation.

b. Registered Nurse license and any additional licensure as an Advanced

Practice Nurse/Certified Nurse Specialist/Adult Psychiatric Nursing or other

license or certification as dictated by the appropriate State(s) Board of

Registered Nursing, if applicable.

c. Certification by the American Nurses Association (ANA) in psychiatric

nursing. This may be any of the following types: Clinical Nurse Specialist in

Child or Adult Psychiatric Nursing, Psychiatric and Mental Health Nurse

Practitioner, or Family Psychiatric and Mental Health Nurse Practitioner.

d. Valid, current, unrestricted DEA/CDS registration, where applicable with

appropriate supervision/consultation by a Network practitioner as applicable

by the state licensing board. For those who possess a DEA registration, the

appropriate CDS registration is required. The DEA/CDS registration must be

valid in the state(s) in which the practitioner will be treating Covered

Individuals.

4. Clinical Psychologist:

a. Valid state clinical psychologist license.

b. Doctoral degree in clinical or counseling, psychology or other applicable

field of study from an institution accredited by the APA within three (3)

years of the time of the practitioner’s graduation.

c. Education/Training considered as eligible for an exception is a practitioner

whose doctoral degree is not from an APA accredited institution, but who is

listed in the National Register of Health Service Providers in Psychology or

is a Diplomat of the American Board of Professional Psychology.

d. Master’s level therapists in good standing in the Network, who upgrade their

license to clinical psychologist as a result of further training, will be allowed

to continue in the Network and will not be subject to the above education

criteria.

5. Clinical Neuropsychologist:

a. Must meet all the criteria for a clinical psychologist listed in C.4 above and

be Board certified by either the American Board of Professional

Neuropsychology (ABPN) or American Board of Clinical Neuropsychology

(ABCN).

b. A practitioner credentialed by the National Register of Health Service

Providers in Psychology with an area of expertise in neuropsychology may

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be considered.

c. Clinical neuropsychologists who are not Board certified, nor listed in the

National Register, will require CC review. These practitioners must have

appropriate training and/or experience in neuropsychology as evidenced by

one or more of the following:

i Transcript of applicable pre-doctoral training, OR

ii Documentation of applicable formal one (1) year post-doctoral

training (participation in CEU training alone would not be considered

adequate), OR

iii Letters from supervisors in clinical neuropsychology (including

number of hours per week), OR

iv Minimum of five (5) years of experience practicing neuropsychology

at least ten (10) hours per week

6. Licensed Psychoanalyst:

a. Applies only to Practitioners in states that license psychoanalysts.

b. Practitioners will be credentialed as a licensed psychoanalyst if they are

not otherwise credentialed as a practitioner type detailed in Credentialing

Policy (e.g. psychiatrist, clinical psychologist, licensed clinical social

worker).

c. Practitioner must possess a valid psychoanalysis state license.

i. Practitioner shall possess a master’s or higher degree from a program

accredited by one of the Regional Institutional Accrediting Bodies and

may be verified from the Accredited Institutions of Post-Secondary

Education, APA, CACREP, or the COAMFTE listings. The institution

must have been accredited within 3 years of the time the Practitioner

graduates.

ii. Completion of a program in psychoanalysis that is registered by the

licensing state as licensure qualifying; or accredited by the American

Board for Accreditation in Psychoanalysis (ABAP) or another

acceptable accrediting agency; or determined by the licensing state to

be the substantial equivalent of such a registered or accredited

program.

(a) A program located outside the United States and its territories

may be used to satisfy the psychoanalytic study requirement

if the licensing state determines the following: it prepares

individuals for the professional practice of psychoanalysis;

and is recognized by the appropriate civil authorities of that

jurisdiction; and can be appropriately verified; and is

determined by the licensing state to be the substantial

equivalent of an acceptable registered licensure qualifying or

accredited program.

(b) Meet minimum supervised experience requirement for

licensure as a psychoanalyst as determined by the licensing

state.

47

(c) Meet examination requirements for licensure as determined

by the licensing state.

D. Participation Criteria and Exceptions for Nurse Practitioners, Physician Assistants.

Piedmont does not credential Nurse Practitioners and Physician Assistants and they are not

listed in Piedmonts provider directory.

1. Process, Requirements and Verifications – Certified Nurse Midwives:

a. The Certified Nurse Midwife (CNM) applicant will submit the

appropriate application and supporting documents as required of any

other Practitioner with the exception of differing information regarding

education, training and board certification.

b. The required educational/training will be at a minimum that required for

licensure as a Registered Nurse with subsequent additional training for

licensure as a Certified Nurse Midwife by the appropriate licensing body.

Verification of this education and training will occur either via primary

source verification of the license, provided that state licensing agency

performs verification of the education, or from the certification board if

that board provides documentation that it performs primary verification

of the professional education and training. If the state licensing agency or

the certification board does not verify education, the education will be

primary source verified in accordance with policy.

c. The license status must be that of CNM as verified via primary source

from the appropriate state licensing agency. Additionally, this license

must be active, unencumbered, unrestricted and not subject to probation,

terms or conditions. Any applicant whose licensure status does not meet

these criteria, or who have in force adverse actions regarding Medicare or

Medicaid will be notified of this and the applicant will be

administratively denied.

d. If the CNM has prescriptive authority, which allows the prescription of

scheduled drugs, their DEA and/or state certificate of prescriptive

authority information will be requested and primary source verified via

normal company procedures. If there are in force adverse actions against

the DEA, the applicant will be notified and the applicant will be

administratively denied.

e. All CNM applicants will be certified by either:

i. The National Certification Corporation for Ob/Gyn and Neonatal

Nursing; or

ii. The American Midwifery Certification Board, previously known

as the American College of Nurse Midwifes.

This certification must be active and primary source verified. If the state

licensing board primary source verifies one of these certifications as a

requirement for licensure, additional verification by Piedmont is not

required. If the applicant is not certified or if their certification has

expired, the application will be submitted for individual review by the

geographic Credentialing Committee.

48

f. If the CNM has hospital privileges, they must have unrestricted hospital

privileges at a CIHQ, TJC, NIAHO, or HFAP accredited hospital, or a

network hospital previously approved by the committee or in the absence

of such privileges, must not raise a reasonable suspicion of future

substandard professional conduct or competence. Information regarding

history of any actions taken against any hospital privileges held by the

CNM will be obtained. Any history of any adverse action taken by any

hospital will trigger a Level II review. Should the CNM provide only

outpatient care, an acceptable admitting arrangement via the

collaborative practice agreement must be in place with a participating

OB/Gyn.

g. The CNM applicant will undergo the standard credentialing process

outlined in Piedmont’s Credentialing Policies. CNMs are subject to all

the requirements of these Credentialing Policies including (but not

limited to): the requirement for Committee review for Level II

applicants, re-credentialing every three years, and continuous sanction

and performance monitoring upon participation in the network.

h. Upon completion of the credentialing process, the CNM may be listed in

Piedmont provider directories. As with all providers, this listing will

accurately reflect their specific licensure designation and these providers

will be subject to the audit process.

i. CNMs will be clearly identified as such:

i. On the credentialing file;

ii. At presentation to the Credentialing Committee; and

iii. On notification to Network Services and to the provider database.

iv. base.

III. HDO Eligibility Criteria

All HDOs must be accredited by an appropriate, recognized accrediting body or in the absence of

such accreditation, Piedmont may evaluate the most recent site survey by Medicare, the

appropriate state oversight agency, or site survey performed by a designated independent

external entity within the past 36 months. Non-accredited HDOs are subject to individual review

by the CC and will be considered for Covered Individual access need only when the CC review

indicates compliance with Piedmont standards and there are no deficiencies noted on the

Medicare or state oversight review which would adversely affect quality or care or patient safety.

HDOs are recredentialed at least every three (3) years to assess the HDO’s continued compliance

with Piedmont standards.

General Criteria for HDOs:

1. Valid, current and unrestricted license to operate in the state(s) in which it will

provide services to Covered Individuals. The license must be in good standing with

no sanctions.

49

2. Valid and current Medicare certification.

3. Must not be currently federally sanctioned, debarred or excluded from participation

in any of the following programs; Medicare, Medicaid, or FEHBP. Note: If, once an

HDO participates in the Piedmont’s programs or provider Network(s), exclusion

from Medicare, Medicaid or FEHBP occurs, at the time of identification, the HDO

will become immediately ineligible for participation in the applicable government

programs or provider Network(s) as well as the Piedmont’s other credentialed

provider Network(s).

4. Liability insurance acceptable to Piedmont.

5. If not appropriately accredited, HDO must submit a copy of its CMS, state site or a

designated independent external entity survey for review by the CC to determine if

Piedmont’s quality and certification criteria standards have been met.

MEDICAL FACILITIES

Facility Type (MEDICAL CARE) Acceptable Accrediting Agencies

Acute Care Hospital CIQH, CTEAM, DNV/NIAHO, HFAP, TJC

Ambulatory Surgical Centers AAAASF, AAAHC, AAPSF, HFAP, IMQ,

TJC

Birthing Center AAAHC, CABC

Clinical Laboratories CLIA, COLA

Convenient Care Centers (CCCs)/Retail

Health Clinics (RHC)

DNV/NIAHO, UCAOA, TJC

Dialysis Center CMS Certification, TJC

Federally Qualified Health Center (FQHC) AAAHC

Free-Standing Surgical Centers AAAASF, AAPSF, HFAP, IMQ, TJC

Home Health Care Agencies (HHA) ACHC, CHAP, CTEAM , DNV/NIAHO,

TJC

Home Infusion Therapy (HIT) ACHC, CHAP, CTEAM, HQAA, TJC

Hospice ACHC, CHAP, TJC

Intermediate Care Facilities CTEAM

Portable x-ray Suppliers FDA Certification

Skilled Nursing Facilities/Nursing Homes BOC INT'L, CARF, TJC

Rural Health Clinic (RHC) AAAASF, CTEAM, TJC

Urgent Care Center (UCC) AAAHC, IMQ, TJC, UCAOA

BEHAVIORAL HEALTH

Facility Type (BEHAVIORAL HEALTH

CARE)

Acceptable Accrediting Agencies

Acute Care Hospital—Psychiatric

Disorders

CTEAM, DNV/NIAHO, HFAP, TJC

Acute Inpatient Hospital – Chemical

Dependency/Detoxification and

Rehabilitation

HFAP, NIAHO, TJC

Adult Family Care Homes (AFCH) ACHC, TJC

Adult Foster Care ACHC, TJC

50

Community Mental Health Centers

(CMHC)

AAAHC, CARF, CHAP, COA, HFAP, TJC

Crisis Stabilization Unit TJC

Intensive Family Intervention Services CARF

51

Intensive Outpatient – Mental Health

and/or Substance Abuse

ACHC, CARF, COA, DNV/NIAHO, TJC

Outpatient Mental Health Clinic CARF, CHAP, COA, HFAP, TJC

Partial Hospitalization/Day Treatment—

Psychiatric Disorders and/or Substance

Abuse

CARF, DNV/NIAHO, HFAP, TJC, for

programs associated with an acute care

facility or Residential Treatment Facilities.

Residential Treatment Centers (RTC) –

Psychiatric Disorders and/or Substance

Abuse

CARF, COA, DNV/NIAHO, HFAP, TJC

REHABILITATION

Facility Type (Behavioral Health Care) Acceptable Accrediting Agencies

Acute Inpatient Hospital – Detoxification

Only Facilities

DNV/NIAHO, HFAP, TJC

Behavioral Health Ambulatory Detox CARF, TJC

Methadone Maintenance Clinic CARF, TJC

Outpatient Substance Abuse Clinics CARF, COA, TJC

52

MEMBER RIGHTS & RESPONSIBILITIES

PIEDMONT MEMBER RIGHTS

Piedmont Members have the right:

• To receive information about Piedmont, its services, its health care providers, and

member’s rights and responsibilities.

• To have their identity protected.

• To file complaints and grievances about Piedmont and/or their PCP or other

providers and to get a timely response.

• To get materials and/or help in other languages and formats if necessary.

• To access, inspect, and receive a copy of their protected health information (PHI)

according to state and federal law. PHI includes personal information such as health

records with addresses and Social Security numbers.

• To request a correction or amendments to their PHI.

• To ask for a list of certain PHI disclosures.

• To be treated with respect, recognizing their right to privacy and dignity.

• To ask for Piedmont’s medical management department’s review guidelines and

clinical practice guidelines.

• To be free from any form of restraint or seclusion used as a means of coercion,

discipline, convenience or retaliation.

• To expect that their records and anything they say to their doctor will be treated

confidentially and will not be released without their consent.

• To receive information from health care providers that they can understand about

available treatment options and alternatives.

• To participate with providers in decisions about their health care. This includes

talking about appropriate or medically necessary treatment options and alternatives

for their condition, regardless of cost or benefit coverage. This also includes the

right to refuse treatment, drugs and/or procedures.

• To know what treatment they will receive, what the expected outcome is, what risks

there are and any side effects and who will be doing the treatment.

• To ask for a second opinion about any medical treatment or procedure.

• To know if care or treatment is part of a research experiment before they have it and

to refuse experimental treatments.

• To file a fair hearing appeal with the Department of Human Services at any time

during the complaint or grievance process.

• To offer suggestions for changes in Piedmont’s member rights and responsibilities.

• To receive health care services without discrimination based on race, color,

ethnicity, age, mental or physical disability, religion, gender, sexual orientation,

national origin or income.

• To choose their own PCP within the limits of the Piedmont network, including the

right to refuse the care of specific providers.

• To expect that their written permission will be obtained before Piedmont gives out

your medical information to anyone except those directly providing your care,

except for purpose specifically permitted by state and federal laws; such as, to make

53

sure that Piedmont members are getting quality care.

• To make an advance directive that tells others about the types of health care they

want to receive if they are unable to speak for themselves.

• To receive information on the cost of your care.

• To exercise their rights freely and be assured that exercising their rights will not

adversely affect the way Piedmont, its providers or state agencies treat them.

• Provide written authorization telling Piedmont if they decide to have someone (such

as a family member, lawyer or other person) represent or act on their behalf during

the complaint or grievance process.

• When emergency services are necessary, they have the right to obtain such services

without unnecessary delay.

PIEDMONT MEMBER RESPONSIBILITIES

Piedmont Members have the responsibility:

• To protect their Piedmont identification card and show it when they get services.

• To let Piedmont and their provider know about important changes that may affect

their membership, health care needs or benefits. Examples of such changes are

changes in name, address or telephone number, if they get pregnant, if their family

size changes, if they or their children have other health insurance or if they move

out of the county or state.

• To get medical services from Piedmont Participating Providers.

• Referrals depend on member’s individual plan.

• To use the emergency room only in cases of an emergency.

• To treat their health care providers with courtesy, consideration, respect and dignity.

This includes arriving on time for scheduled appointments and canceling

appointments when they cannot keep them.

• To ask questions to help them understand their health problems and to work with

their provider and Piedmont on agreed upon treatment goals.

• To follow treatment plans and instructions for care that they have agreed on with

their provider.

• To learn about any procedure or treatment and to think about it before it is done.

• To report all of their symptoms, problems and related health information to their

PCP or other provider.

• To tell their PCP about their medical history.

CONFIDENTIALITY & PRIVACY OF PIEDMONT MEMBER MEDICAL RECORDS &

PROTECTED HEALTH INFORMATION (PHI) Piedmont follows the regulations in the Health Insurance Portability and Accountability Act of

1996 (HIPAA) including the HITECH Act of 2009. This law protects the privacy of Member

medical records and health information. Piedmont also follows all other state and federal

regulations regarding privacy of medical records and health information. A Member’s medical

record and other information (which includes information relating to HIV/AIDS, substance abuse

54

and behavioral health treatments) received by Piedmont will be kept confidential (private) as

required by law.

MEMBER NOTICE OF PRIVACY PRACTICES

The following Member Notice of Privacy Practices details how Piedmont makes sure protected

health information is kept private:

NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION

THIS NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION ABOUT YOU

MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS

INFORMATION. PLEASE REVIEW IT CAREFULLY.

Your Rights

When it comes to your health information, you have certain rights. This section explains your

rights and some of our responsibilities to help you exercise those rights. You have the right to:

Request a copy of health and claim records

• You may request a copy of your health records, claim records, or other health information

we have about you.

• We will provide a copy or a summary of your health and claims records, usually within 30

days of your request.

Request a correction to your health and claim records

• You may request a correction to your health and claims records if you think they are

incorrect or incomplete.

• We may deny your request, but we will provide an explanation in writing within 60 days.

Request confidential communications

• You may request that we contact you in a specific way (i.e. home or office phone) or to send

mail to a different address.

• We will consider all reasonable requests.

Request to limit what we use or share

• You may request that we do not use or share certain health information for treatment,

payment, or our operations.

• We may deny your request if it would affect your care.

Request a list of those with whom we have shared information

• You may request a list of the times we have shared your health information for six years

prior to the date you ask, who we shared it with, and why.

• We will include all of the disclosures except for those about treatment, payment, health care

55

operations, and certain other disclosures (such as any you asked us to make).

Request a copy of this privacy notice

• You may request a paper copy of this notice at any time, even if you have agreed to receive

the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legal guardian,

that person can exercise your rights and make choices about your health information.

• We will confirm that the person has the appropriate authority and can act for you before we

take any action.

File a complaint if you feel that your rights are violated

• You can complain if you feel we have violated your rights by contacting us using the contact

information on the back of your member ID card, or use the information located at the end of

this notice to contact Piedmont.

• You can file a complaint by sending a letter to the U.S. Department of Health and Human

Services Office for Civil Rights, or by calling 1-877-696-6775, or by visiting:

www.hhs.gov/ocr/privacy/hipaa/complaints

• We will not take action against you for filing a complaint.

How we use your Protected Health Information (PHI)

We may collect, use and share your Protected Health Information (PHI) for the following

reasons and as allowed or required by law, including the HIPAA Privacy Rule:

For Payment:

• We can use and disclose your PHI as we manage your account, your benefits, or to pay

claims for health care you get through your plan.

Example: We share PHI with your provider to confirm your benefits and to help pay claims.

For Treatment:

• We do not provide treatment. Treatment is performed by a health care provider, such as

your doctor or a hospital.

• We can use your health information and share it with professionals who are treating you.

Example: A doctor sends us information about your diagnosis and treatment plan so we can

arrange additional services.

For Health Care Operations:

• We can use and disclose your PHI for health care operations, to improve quality of care and

services you get from Piedmont.

• We can use and disclose your information to run our organization and contact you when

56

necessary.

Example: We use health information about you to develop better services for you through case

management or care coordination.

To Administer Your Plan:

• We may disclose your health information to your health plan sponsor for plan

administration.

• We are not allowed to use genetic information to decide whether we will give you coverage

and the price of that coverage.

Example: Your company contracts with us to provide a health plan, and we provide your

company with certain statistics to explain the premiums we charge.

How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that

contribute to the public good, such as public health and research. We have to meet many

conditions in the law before we can share your information for these purposes.

For more information, please view:

www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html

• Help with public health and safety issues

We can share health information about you for certain situations such as:

o Preventing disease.

o Helping with product recalls.

o Reporting adverse reactions to medications.

o Reporting suspected abuse, neglect, or domestic violence.

o Preventing or reducing a serious threat to anyone’s health or safety.

• Conduct research

We can use or share your information for health research purposes.

• Comply with the law

We will share information about you if state or federal laws require it, including with the

Department of Health and Human Services (HHS).

Example: Sharing information with HHS to ensure we are complying with federal privacy

law or during a federal audit.

• Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.

• Work with a medical examiner or funeral director

We can share health information about you with a coroner, medical examiner, or funeral

57

director if you pass away.

• Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you:

o For workers’ compensation claims.

o For law enforcement purposes or with a law enforcement official.

o With health oversight agencies for activities authorized by law.

o For special government functions such as military, national security, and presidential

protective services.

• Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or

in response to a subpoena.

Your Choices

For certain health information, you can provide us with your choices regarding what we share. If

you have a clear preference for how we share your information in the situations described above,

please communicate that preference to us.

Authorizations

The standard method to communicate your preference is through an authorization. We will

request authorizations to use and disclose your PHI for any reason not stated in this notice.

You may revoke the authorization at any time in writing. Once revoked, we will stop using your

PHI for the authorized purpose.

You can choose who we share PHI with, for example:

• You can tell us to share information with your family, close friends, or others involved in

payment for your care.

• You can choose what PHI we share in a disaster relief situation.

If you are not able to provide us your preference, for example if you are unconscious, we may

share your information if we believe it is in your best interest. We may also share your

information when needed to lessen a serious and imminent threat to your health or safety.

Marketing

We will never share your information for marketing purposes or sell your information without

your written permission. You can choose whether to authorize us to share your information for

marketing purposes.

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health

information.

• We will let you know promptly if a breach occurs that may have compromised the privacy or

58

security of your information.

• We must follow the duties and privacy practices described in this notice and give you a

copy.

• We will not use or share your information other than as described here unless you tell us in

writing. If you tell us we can, you may change your mind at any time. Let us know in

writing if you change your mind.

• For more information, please view:

www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html

Contacting you

We, including our affiliates and/or vendors, may contact you using various methods, including

automated reminder calls, etc. The calls may be to let you know about treatment options or

other health-related benefits and services. If you do not want to be contacted by phone, please

let the caller know, and we will not reach out to you thereafter. Or, you can call the customer

service number on the back of your member ID card and we will ensure all affiliates and

vendors know not to call you regarding reminders.

Changes to the Terms of this Notice

We can change the terms of this notice at our discretion and the change will apply to all

information we have about you. The new notice will be available on our website www.pchp.net

under “Privacy Info” and by mail as requested.

Effective date of this notice

The original effective date of this Notice was April 14, 2003. The most recent revision date is

indicated in the footer of this Notice.

Contact Information

For more information about our privacy practices, to exercise your rights under this notice, or to

file a complaint about a privacy matter, you should contact us:

• By Mail:

Attention: Privacy Officer

Piedmont Community Health Plan

2316 Atherholt Rd.

Lynchburg, VA 24501

• By Phone:

Local: (434) 947-4463

Toll-Free: (800) 400-7247

TTY 711 PCHP.NPP (Iss. 2017.11.17)

59

PROVIDER APPEALS, DISPUTES AND GRIEVANCES

COMPLAINTS, GRIEVANCES

Overview

Members and their representatives (including providers) may file a Complaint or Grievance if

they are not able to resolve issues through informal channels with Piedmont.

Members may agree to be represented by their health care provider in the filing of a Complaint

or Grievance. Members may also request a provider’s written certification when seeking an

expedited review of a Complaint or Grievance. The provider’s written certification for

expedited review must state why the usual timeframe for deciding the appeal would jeopardize

the member's life, health or ability to attain, maintain or regain maximum function.

For a provider to represent the Member in the conduct of a Grievance, the provider must obtain

written consent of the Member. A provider may not require a Member to sign a document

authorizing the provider to file a Grievance as a condition of treatment. The consent form must

maintain the following elements:

• The Member’s name, address, date of birth, and identification number

• If the Member is a minor or is legally incompetent, the name address and relationship to

the Member of the person who signed the consent

• The name, address, and Piedmont provider identification number of the provider who is

receiving the Member’s consent to file a Complaint or Grievance

• The name and address of Piedmont

• An explanation of the specific service/item for which coverage was provided or denied

to the Member to which the consent will apply

• The following statement – “The Member or the Member’s representative may not

submit a Grievance concerning the services/items listed in this consent form unless the

Member or the Member’s representative rescinds consent in writing. The Member or the

Member’s representative has the right to rescind consent at any time during the

Grievance process”.

• The following statement – “The consent of the Member or the Members representative

shall be automatically rescinded if the provider fails to file a Grievance or fails to

continue to prosecute the Grievance through the second level Grievance process”

• The following statement – “The Member or the Members representative, if the Member

is a minor or legally incompetent, has read, or has been read this consent form, and has

had it explained to his/her satisfaction. The Member or the Member’s representative

understands the information in the Members consent form.”

• The dated signature of the Member, or the Member’s representative, and the dated

signature of a witness

A Member who consents to the filing of a Complaint or Grievance by a health care provider

may not file a separate Grievance. The Member retains the right to rescind consent throughout

the Grievance.

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The Quality Department has the overall responsibility for the management of the Member

Complaint and Grievance process. This includes:

• Documenting individual Complaints and Grievances

• Coordinating resolutions

• Maintaining logs and records of the Complaints and Grievances

• Tracking, trending and reporting data

The Piedmont Grievance Coordinator will serve as the primary contact person for the

Complaint and Grievance process with the Piedmont Appeals Coordinator serving as the back-

up contact person.

The Appeals Department, in collaboration with the Customer Service Department and Provider

Relations Department, is responsible for informing and educating Members and providers about

a Member’s right to file a Complaint or Grievance and for assisting Members in filing a

Complaint or Grievance.

Members are advised of their Complaint, Grievance and the Complaint, Grievance and at the

time of enrollment and at least annually thereafter. Members are provided this information via

the Member handbook, Member newsletters and the Piedmont Web site. The information

provided to Members includes, but is not limited to:

• The method for filing a Complaint, Grievance or for requesting including procedural

steps and timeframes for filing each level of a Complaint or Grievance or for requesting

a Notification of Member’s rights related to Complaints, Grievances including the right

to voice Complaints or Grievances about Piedmont or care provided.

• The availability of assistance from Piedmont with filing a Complaint, Grievance

along with Piedmont toll-free number and address for filing Complaints, Grievances

or.

• Upon request, reasonable assistance with the Complaint, Grievance process is

provided to Members. This includes but is not limited to providing oral

interpreter services and toll free number

• TTY/TDD and sign language interpreter capability. Piedmont staff is trained to

respond to Members with disabilities with patience, understanding and respect.

PROCESS AND TIMEFRAMES FOR COMPLAINTS AND GRIEVANCES Piedmont will accept Complaints and Grievances telephonically via a toll-free telephone

number, in writing or by facsimile. If the Member has a sensory impairment, Piedmont will

assign a representative to assist that Member throughout the Grievance system process.

Piedmont will accept Complaints and Grievances through a TTY/TDD line, Braille; tape or

CD and other commonly accepted alternative forms of communication. If a Member should

need a sign language interpreter, Piedmont will provide one at no cost to the Member.

Additionally, Piedmont will train its staff to be aware of speech limitations of some Members

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with disabilities and treat these Members with patience, understanding and respect.

If a Complaint or Grievance is received in a written format (surface mail, facsimile, Braille),

it will be forwarded to the Coordinator.

The Coordinator will assign the appropriate category (Complaint or Grievance

request), level (first, second, expedited or external) and ensure the required timeframe.

Filing Grievances – Timelines

Member has 60 days after event to file a grievance.

Once the Complaint or Grievance has been verified, acknowledged and documented in the

Complaint and Grievance database, the Coordinator will start the research process.

Piedmont will issue an acknowledgement letter upon receipt of the Complaint or

Grievance.

If a provider believes that the usual timeframes for deciding a Member’s Complaint or

Grievance will endanger their health, the provider can call Piedmont at 434-947-4463 and

request an expedited review of the Complaint or Grievance. This request must be

accompanied by a Provider Certification letter stating that the usual timeframe for deciding

the Complaint or Grievance will endanger the Member’s health. This letter should be faxed to

the attention of the Complaints and Grievance Department at 434-947-4463. Piedmont will

make a reasonable effort to obtain the certification from the provider.

If Piedmont is unable to obtain a Provider Certification from the provider within three (3)

Business Days of a request for an expedited Complaint or Grievance, the Complaint or

Grievance will be decided within the standard timeframes.

Complaint and Grievance Reviews

Piedmont Complaints and Grievances will be reviewed by the grievance coordinator and/or

Medical Director. Additional department level support will be accessed as needed based on

member’s complaint or grievance.

Timeframes for Resolution of Complaints, Grievances and Expedited and

External Reviews

Piedmont resolves each Complaint or Grievance as expeditiously as the Member’s health

requires but no later than the timeframe identified by NCQA and CMS.

PROVIDER APPEALS AND DISPUTES

Piedmont offers providers an appeal and dispute process for expressing dissatisfaction with

a Piedmont decision that directly impacts the provider and a formal appeals process to

request reversal of a denial by Piedmont. The definitions and processes for Provider

Appeals and a Provider Disputes are as follows:

Provider Appeal – A request from a Provider for reversal of a denial by Piedmont, with

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regard to the three (3) major types of issues that are to be addressed in a Provider Appeal

system as outlined in the Provider Dispute Resolution System. The three (3) types of

Provider Appeals issues are:

1. Provider credentialing denial by Piedmont.

• If a provider communicates dissatisfaction with a credentialing determination,

Credentials Committee, at its next scheduled meeting, will review information

provided by the provider and make a determination. If the provider’s credentialing

or recredentialing is denied, the provider has thirty (30) Business Days from

receipt of notice to file an appeal.

2. Claims denied by Piedmont for Participating Providers participating in Piedmont’s

network. This includes payment denied for services already rendered by the Participating

Provider to the Member or for pre-service medical necessity denials.

• You will hear Provider Appeals and disputes and make a determination within

sixty (60) days for post-service appeals. Preservice appeal decisions will be made

within CMS and NCQA timeframes according to the level of appeal.

3. Termination of Participating Provider Agreement by Piedmont based on quality of care or

service.

• Suspension, non-renewal, or termination of Participating Provider’s participation

initiated by Piedmont entitles the Participating Provider to an appeal hearing

upon timely and proper request by the Participating Provider for said appeal for

any of the following reasons:

o Business need; o Breach of Agreement; o Suspected fraud and abuse; o Non-compliant behavior that jeopardizes Member satisfaction;

o Temporary sanction, suspension or restriction by Medicare, any

licensing board or professional review organization (Organizational

Providers only*); and/or

o Failure to immediately notify Health Plan of substantive changes in credentialing

information including, but not limited to, adverse licensure actions,

termination/cancellation of professional liability insurance or sanctions from

billing private, federal or state health insurance programs (Organizational

Providers only*).

• Participating Providers will have five (5) Business Days from receipt of notice to

file a written request for a hearing to appeal suspension, non-renewal, or

termination of Piedmont participation. Requests for a hearing shall:

o Specify in detail the reason(s) the Participating Provider wishes to contest the

suspension, non-renewal or termination decision;

o Be delivered certified or registered mail to the Piedmont contact who executed

the notice to Participating Provider of non-renewal/termination; o Specify if Participating Provider intends to be represented by an attorney at the

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hearing; o Include the name, address, phone, fax and email (if available) of Participating

Provider’s attorney, if applicable;

o Include a list of the name(s), title(s), address(es) and phone number(s) of any

witnesses expected to testify on behalf of Participating Provider at the

hearing; and

o Include copies of all additional information Participating Provider wishes to

present at the hearing.

Provider Dispute – A written communication to Piedmont, made by a contracted provider,

expressing dissatisfaction with a Health Plan decision that directly impacts the provider

payment. This does not include decisions concerning Medical Necessity.

Provider Dispute Process - When a written Provider Dispute is received, it will be forwarded

to the appropriate department within Piedmont for resolution. The dispute will be researched

and responded to within 60 days of receipt.

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REGULATORY COMPLIANCE

CULTURAL COMPETENCY

Cultural Competency & Interpretive Services for the Disabled and Those with

Limited English Proficiency

Members are to receive covered services without concern about race, ethnicity, national

origin, religion, gender, age, gender identification, mental or physical disability, sexual

orientation, genetic information or medical history, ability to pay or ability to speak

English.

Piedmont expects contracted providers to treat all Members with dignity and respect as

required by federal law. Title VI of the Civil Rights Act of 1964 prohibits discrimination on

the basis of race, color, and national origin in programs and activities receiving federal

financial assistance, such as Medicare or Medicaid.

Piedmont policies conform with federal government Limited English Proficiency (LEP)

guidelines stating that programs and activities normally provided in English must be

accessible to LEP persons. Services must be provided in a culturally effective manner to all

Members, including those with Limited English Proficiency (LEP) or reading skills, those

with diverse cultural and ethnic backgrounds, those who are deaf or hard of hearing, the

homeless and individuals with physical and mental disabilities. To ensure Members’

privacy, they must not be interviewed about medical or financial issues within hearing

range of other patients.

In compliance with federal and state requirements:

• Piedmont takes reasonable steps to provide meaningful access to health care and benefits

for Members with Limited English Proficiency (LEP) and Members with disabilities.

Piedmont provides the following auxiliary aids and services free of charge:

o Written information in other formats (large print, audio, accessible electronic formats)

for the visually impaired.

o TTY Service using VA Relay to communicate with the hearing impaired.

o Qualified sign language interpreters for the hearing impaired.

o Language line with qualified interpreters to communicate with non-English speaking

individuals.

o Information written in other languages for non-English speaking individuals.

Contact our Customer Service Department to learn more about these services.

• Piedmont must include appropriate instructions on all materials about how to

access, or receive assistance with accessing, desired materials in an alternate

format.

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MAINSTREAMING

Pursuant to their Agreement, Piedmont Participating Providers must not intentionally segregate Members in any way from other persons receiving services.

Piedmont investigates Complaints and takes affirmative action so that Members are provided

covered services without regard to race, color, creed, sex, religion, age, national origin,

ancestry, marital status, sexual orientation, language, MA status, health status, disease or pre-

existing condition, anticipated need for health care or physical or mental handicap, except

where medically indicated. Examples of prohibited practices include, but are not limited to,

the following:

• Denying or not providing a Member any covered service or access to a participating facility

within the Piedmont Network. Piedmont policy provides access to complex interventions

such as cardiopulmonary resuscitations, intensive care, transplantation, and rehabilitation

when Medically Necessary. Health care and treatment necessary to preserve life must be

provided to all persons who are not terminally ill or permanently unconscious, except where

a competent Member objects to such care on his/her own behalf.

• Subjecting a Member to segregated, separate, or different treatment, including a different

place or time from that provided to other Members, public or private patients, in any manner

related to the receipt of any Piedmont covered service, except where Medically Necessary.

• The assignment of times or places for the provision of services on the basis of the race,

color, creed, religion, age, sex, national origin, ancestry, marital status, sexual orientation,

income status, program membership, language, MA status, health status, disease or pre-

existing condition, anticipated need for health care or physical or mental disability of the

participants to be served.

HIPAA AND CONFIDENTIALITY

HIPAA Notice of Privacy Practices

Piedmont maintains strict privacy and confidentiality standards for all medical records and

Member health care information, according to federal and state standards. Providers can

access up-to-date Health Insurance Portability and Accountability Act (HIPAA) Notice of

Privacy Practices on our web-site at www.pchp.net. This includes explanations of

Members’ rights to access, amend, and request confidential communication of, request

privacy protection of, restrict use and disclosure of, and receive an accounting of

disclosures of Protected Health Information (PHI).

Confidentiality Requirements

Providers are required to comply with all federal, state and local laws and regulations

governing the confidentiality of medical information including all laws and regulations

pertaining to, but not limited to the Health Insurance Portability and Accountability Act

(HIPAA) and applicable contractual requirements.

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Providers are contractually required to safeguard and maintain the confidentiality of data

that addresses medical records and confidential provider and Member information, whether

oral or written in any form or medium. All “individually identifiable health information”

held or transmitted by a covered entity or its business associate, in any form or media,

whether electronic, paper, or oral is considered confidential PHI.

“Individually identifiable health information” is information, including demographic data,

that relates to:

• The individual’s past, present or future physical or mental health or condition

• The provision of health care to the individual

• The past, present, or future payment for the provision of health care to the individual

• Information that identifies the individual or for which there is a reasonable basis to

believe it can be used to identify the individual

• Individually identifiable health information includes many common

identifiers (e.g., name, address, birth date, Social Security Number)

Excluded from PHI are employment records that a covered entity maintains in its capacity

as an employer and education and certain other records subject to, or defined in, the

Family Educational Rights and Privacy Act, 20 U.S.C. § 1232g.

Providers’ offices and other sites must have mechanisms in place that guard against

unauthorized or inadvertent disclosure of confidential information to anyone outside of

Piedmont.

Release of data to third parties requires advance written approval from DHS, except for

releases of information for the purpose of individual care and coordination among

providers, releases authorized by Members or releases required by court order, subpoena or

law.

Member Privacy Rights

Piedmont’s privacy policy assures that all Members are afforded the privacy rights permitted

under HIPAA and other applicable federal, state, and local laws and regulations, and

applicable contractual requirements. Our privacy policy conforms with 45 C.F.R. (Code of

Federal Regulations): relevant sections of the HIPAA that provide Member privacy rights

and place restrictions on uses and disclosures of protected health information (§164.520, 522,

524, 526 and 528).

Our policy also assists Piedmont personnel and providers in meeting the privacy

requirements of HIPAA when Members or authorized representatives exercise privacy

rights through privacy request, including:

• Making information available to Members or their representatives about Piedmont’s

practices regarding their PHI

• Maintaining a process for Members to request access to, changes to, or

restrictions on disclosure of their PHI

• Providing consistent review, disposition, and response to privacy requests within

required time standards

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• Documenting requests and actions taken

Member Privacy Requests

Members may make the following requests related to their PHI (privacy requests) in

accordance with federal, state, and local law:

• Make a privacy Complaint

• Receive a copy of all or part of their designated record set

• Amend records containing PHI

• Receive an accounting of health plan disclosures of PHI

• Restrict the use and disclosure of PHI

• Receive confidential communications

• Receive a Notice of Privacy Practices

A privacy request must be submitted by the Member or Member’s authorized representative.

A Member’s representative must provide documentation or written confirmation that he or

she is authorized to make the request on behalf of the Member or the deceased Member’s

estate. Except for requests for a health plan Notice of Privacy Practices, requests from

Members or a Member’s representative must be submitted to Piedmont in writing.

Privacy Process Requirements

Piedmont’s processes for responding to Member privacy requests shall include components for

the following:

Verification

If the requester is the Member, Piedmont personnel shall verify the Member’s identity;

verification examples include asking for the last four digits of Member’s Social Security

Number, Member’s address and Member’s date of birth. If the requester is not the Member,

Piedmont personnel shall require an Authorization for Use or Disclosure completed by the

Member to verify the requester’s authority to obtain the Member’s information. If the

requester identifies him/herself as a Member’s authorized representative, Piedmont

personnel shall require a healthcare Power of Attorney (POA) or comparable document for a

representative to act on behalf of the Member.

Review, Disposition, and Response

Piedmont personnel review and disposition of privacy requests shall comply with applicable

federal, state, and local laws and regulations, and applicable contractual requirements,

including those that govern use and disclosure of PHI. Responses to privacy requests shall

conform to guidelines prescribed by HIPAA, including response time standards, and shall

include a notice of administrative charges, if any, for granting the request.

Use and Disclosure Guidelines

Piedmont personnel are required to use and disclose only the minimum amount of

information necessary to accommodate the request or carry out the intended purpose.

Limitations

A privacy request may be subject to specific limitations or restrictions as required by

law. Piedmont personnel may deny a privacy request under any of the following

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conditions:

• Piedmont does not maintain the records containing the PHI

• The requester is not the Member and Piedmont personnel are unable to verify

his/her identity or authority to act as the Member’s authorized representative

• The documents requested are not part of the designated record set (e.g.,

credentialing information)

• Access to the information may endanger the life or physical safety of or otherwise

cause harm to the Member or another person

• Piedmont is not required by law to honor the particular request (e.g., accounting

for certain disclosures)

• Accommodating the request would place excessive demands on Piedmont or its

personnel’s time and Piedmont resources and is not contrary to HIPAA

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FRAUD AND ABUSE

Piedmont Compliance Program

Piedmont is committed to a policy of zero tolerance for fraudulent insurance acts that

victimize Piedmont and its’ stakeholders. Accordingly, Piedmont maintains a robust

Compliance Program. Piedmont’s Compliance Program is designed to oversee the

development, implementation and maintenance of a compliance and privacy program that

meets or exceeds federal and state laws and regulations, as well as contractual and

accreditation obligations. Piedmont is committed to ethical and legal conduct that is

compliant with all relevant laws and regulations, and to correcting wrongdoing whenever it

may occur in the administration of any of our plans. This commitment encompasses our

organization and any of the parties that we contract with to provide services related to the

administration of our plans.

Defining Fraud, Waste, and Abuse

• Fraud – An intentional deception or misrepresentation made by a person or entity

that knows or should know the deception or misrepresentation could result in some

unauthorized benefit to himself/herself or some other person(s) or entity(ies). The

Fraud can be committed by many entities, including Piedmont, a subcontractor, a

Provider, a State employee, or a Member, among others.

• Waste – Waste occurs when an act of carelessness in performance and/or lack of

training result in otherwise unnecessary repetition of services or cost.

• Abuse – Any practices that are inconsistent with sound fiscal, business, or medical

practices, and result in unnecessary costs to the MA Program, or in reimbursement

for services that are not Medically Necessary or that fail to meet professionally

recognized standards or contractual obligations for health care in a managed care

setting. The Abuse can be committed by Piedmont, a subcontractor, Provider, State

employee, or a Member, among others. Abuse also includes Member practices that

result in unnecessary cost to the MA Program, Piedmont, a subcontractor, or

Provider.

Reporting Fraud and Abuse Providers and Members can report suspected Fraud and Abuse directly to the Virginia Department of Health Professions (DHP) Enforcement Division by:

Phone: 1-800-533-1560 or (804) 367-4691

Fax: (804) 527-4424

Email: enfcomplaints@dhp.virginia.gov

Mail: Virginia Department of Health Professions

Enforcement Division

Perimeter Center

9960 Mayland Drive, Suite 300

Henrico, VA 23233-1463

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The Department of Health Professions receives complaints about Virginia healthcare

practitioners who may have violated a regulation or law. Complaints for all the licensing and

regulatory Boards are received and processed by the agency's Enforcement Division.

ATTENTION: The Department of Health Professions cannot guarantee anonymity. A copy

of your complaint and any supporting documentation provided by you may be shared with

the subject of the complaint (practitioner or licensee) pursuant to the Code of Virginia §

54.1-2400.2 (G). Using the online complaint form may help preserve your anonymity. If you

wish to submit an anonymous complaint, please ensure you check the “Anonymous” box on

the online complaint form, and do not include any information on the complaint form or

supplemental documents that reveals your identity. If you wish to use an alternative method

for filing a complaint (see below) and wish to remain anonymous, do not include any

information on the complaint form, envelope, email address, body of email, or supplemental

documents that reveals your identity.

Suspected Fraud and Abuse can also be reported to Piedmont’s Compliance Department by:

Email: pchp.compliance@pchp.net

Phone: Piedmont/Centra Compliance Hot Line: 1-800-713-4703

Customer Service Team: 1-800-400-7247

Mail: Fraud Investigation Department

Piedmont Community Health Plan

2316 Atherholt Road

Lynchburg, VA 24501

When you report fraud to Piedmont, you may remain anonymous. All reports are kept

strictly confidential.

Examples of Risks for Fraud, Waste and Abuse Prescriber Fraud, Waste and Abuse

• Illegal remuneration schemes: Prescriber is offered, or paid, or solicits, or

receives unlawful remuneration to induce or reward the prescriber to write

prescriptions for drugs or products.

• Prescription drug switching: Drug switching involves offers of cash payments or

other benefits to a prescriber to induce the prescriber to prescribe certain

medications rather than others.

• Script mills: Provider writes prescriptions for drugs that are not medically

necessary, often in mass quantities, and often for patients that are not theirs.

These scripts are usually written, but not always, for controlled drugs for sale

on the black market, and might include improper payments to the provider.

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• Provision of false information: Prescriber falsifies information (not consistent

with medical record) submitted through a prior authorization or other formulary

oversight mechanism in order to justify coverage. Prescriber misrepresents the

dates, descriptions of prescriptions or other services furnished, or the identity of

the individual who furnished the services.

• Theft of prescriber’s DEA number or prescription pad: Prescription pads and/or

DEA numbers can be stolen from prescribers. This information could illegally

be used to write prescriptions for controlled substances or other medications

often sold on the black market. In the context of e- prescribing, includes the

theft of the provider’s authentication (log in) information.

Member Fraud, Waste and Abuse Risks

• Misrepresentation of status: A Member misrepresents personal information,

such as identity, eligibility, or medical condition in order to illegally receive the

drug benefit. Enrollees who are no longer covered under a drug benefit plan

may still attempt to use their identity card to obtain prescriptions.

• Identity theft: Perpetrator uses another person’s Piedmont identification

card to obtain prescriptions.

• Prescription forging or altering: Where prescriptions are altered, by

someone other than the prescriber or pharmacist with prescriber approval, to

increase quantity or number of refills.

• Prescription diversion and inappropriate use: Members obtain prescription

drugs from a provider, possibly for a condition from which they do not suffer,

and gives or sells this medication to someone else. Also can include the

inappropriate consumption or distribution of a Member’s medications by a

caregiver or anyone else.

• Resale of drugs on black market: Member falsely reports loss or theft of drugs or

feigns illness to obtain drugs for resale on the black market.

• Prescription stockpiling: Member attempts to “game” their drug coverage by

obtaining and storing large quantities of drugs to avoid out-of-pocket costs, to protect

against periods of non-coverage (i.e., by purchasing a large amount of prescription

drugs and then disenrolling), or for purposes of resale on the black market.

• Doctor shopping: Member or other individual consults a number of doctors for the

purpose of inappropriately obtaining multiple prescriptions for narcotic painkillers

or other drugs. Doctor shopping might be indicative of an underlying scheme, such

as stockpiling or resale on the black market.

• Improper Coordination of Benefits: Improper coordination of benefits where

Member fails to disclose multiple coverage policies, or leverages various coverage

policies to “game” the system.

• Marketing Schemes: A Member may be victimized by a marketing scheme where a

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sponsor, or its agents or brokers, violates the marketing guidelines, or other

applicable Federal or state laws, rules, and regulations to improperly enroll a MA

beneficiary.

Pharmacy Fraud, Waste and Abuse

• Inappropriate billing practices: Inappropriate billing practices at the pharmacy

level occur when pharmacies engage in the following types of billing practices:

o Incorrectly billing for secondary payers to receive increased reimbursement.

o Billing for non-existent prescriptions.

o Billing multiple payers for the same prescriptions, except as required for

coordination of benefit transactions.

o Billing for brand when generics are dispensed.

o Billing for non-covered prescriptions as covered items.

o Billing for prescriptions that are never picked up (i.e., not reversing claims that

are processed when prescriptions are filled but never picked up).

o Billing based on “gang visits,” (e.g., a pharmacist visits a nursing home and

bills for numerous pharmaceutical prescriptions without furnishing any

specific service to individual patients).

o Inappropriate use of dispense as written (DAW) codes.

o Drug diversion.

o Prescription splitting to receive additional

dispensing fees.

• Prescription drug shorting: Pharmacist provides less than the prescribed quantity

and intentionally does not inform the Member or make arrangements to provide the

balance but bills for the fully- prescribed amount.

• Bait and switch pricing: Bait and switch pricing occurs when a Member is led to

believe that drug will cost one price, but at the point of sale the Member is charged

a higher amount.

• Prescription forging or altering: Where existing prescriptions are altered, by an

individual without the prescriber’s permission to increase quantity or number of

refills.

• Dispensing expired or adulterated prescription drugs: Pharmacies

dispense drugs that are expired, or have not been stored or handled in

accordance with manufacturer and FDA requirements.

• Prescription refill errors: A pharmacist provides the incorrect number of

refills prescribed by the provider.

• Illegal remuneration schemes: Pharmacy is offered, or paid, or solicits, or

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receives unlawful remuneration to induce or reward the pharmacy to switch

Members to different drugs, influence prescribers to prescribe different drugs,

or steer Members to plans.

Provider Screening of Employees and Contractors for Exclusion from Participation in

Federal Health Care Programs

Overview

Under both State and Federal law, DHS and Piedmont are generally prohibited from paying

for any items or services furnished, ordered, or prescribed by individuals or entities

excluded from the MA Program as well as other Federal health care programs. Medicare

providers and managed care entities who employ or enter into contracts with excluded

individuals or entities to provide items or services to Medicare recipients when those

individuals or entities are excluded from participation in any Medicare, Medicaid, or other

Federal health care programs are subject to termination of their enrollment in and exclusion

from participation in the MA Program and all Federal health care programs, recoupment of

overpayments, and imposition of civil monetary penalties.

The amount of the Medicare overpayment for such items or services is the actual amount of

Medicare or Medicaid dollars that were expended for those items or services. When

Medicare or Medicaid funds have been expended to pay an excluded individual’s salary,

expenses, or fringe benefits, the amount of the overpayment is the amount of those expended

Medicare or Medicaid funds.

All employees, vendors, contractors, service providers, and referral sources whose functions

are a necessary component of providing items and services to MA recipients, and who are

involved in generating a claim to bill for services, or are paid by Medicare (including salaries

that are included on a cost report submitted to DHS), should be screened for exclusion before

employing and/or contracting with them and, if hired, should be rescreened on an ongoing

monthly basis to capture exclusions and reinstatements that have occurred since the last

search. Examples of individuals or entities that providers should screen for exclusion

include, but are not limited to:

• Individual or entity who provides a service for which a claim is submitted to Medicare;

• Individual or entity who causes a claim to be generated to Medicare;

• Individual or entity whose income derives all, or in part, directly or indirectly, from

Medicare funds;

• Independent contractors if they are billing for Medicare services;

• Referral sources, such as providers who send a Medicare recipient to another provider for additional services or second opinion related to medical condition.

Procedure

To protect the MA Program against payments for items or services furnished, ordered, or

prescribed by excluded individuals or entities; to establish sound compliance practices, and

to prevent potential monetary and other sanctions, providers should:

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1. Develop policies and procedures for screening of all employees and contractors

(both individuals and entities), at time of hire or contracting; and, thereafter, on an

ongoing monthly basis to determine if they have been excluded from participation in

federal health care programs;

2. Use the following databases to determine exclusion status:

a. List of Excluded Individuals/Entities (LEIE): data base maintained by

HHSOIG that identifies individuals or entities that have been excluded

nationwide from participation in any federal health care program. An individual

or entity included on the LEIE is ineligible to participate, either directly or

indirectly, in the MA Program.

b. System for Award Management (SAM): a U.S. Government owned and

operated free web site containing entity registration records and exclusion

records. Exclusion records identify those parties excluded from receiving certain

federal contracts, subcontracts, and financial and non- financial assistance and

benefits.

The SAM exclusions database, located at https://www.sam.gov, is the official government-wide system of records of debarments, suspensions, and other exclusionary actions.

c. Social Security Administration Death Master File (SSADMF): a Social

Security Administration (SSA) extract of death information on the

NUMIDENT, the electronic database that contains SSA records of Social

Security Numbers (SSN) assigned to individuals since 1936, and includes, if

available, the deceased individual’s SSN, first name, middle name, surname,

date of birth, and date of death: https://www.ssdmf.com

d. National Plan and Provider Enumeration System (NPPES): a CMS run

online registry of National Provider Identifier (NPI) numbers:

https://npiregistry.cms.hhs.gov

3. To report suspected exclusions, contact:

HHS, OIG, OI

Attn: Exclusions Branch

P.O. Box 23871

Washington, DC 20026

Telephone: (202) 691-2311

Fax: (202) 691-2298

Email: sanction@oig.hhs.gov

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4. Develop and maintain auditable documentation of screening efforts, including dates

the screenings were performed and the source data checked and its date of most

recent update; and periodically conduct self-audits to determine compliance with this

requirement.

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GLOSSARY

Abuse — Any practices that are inconsistent with sound fiscal, business, or medical practices,

and result in unnecessary costs to the MA Program, or in reimbursement for services that are not

Medically Necessary or that fail to meet professionally recognized standards or contractual

obligations (including the terms of the RFP, Agreement, and the requirements of state or federal

regulations) for health care in a managed care setting. The Abuse can be committed by the

Piedmont, subcontractor, Health Care Provider, State employee, or a Member, among others.

Abuse also includes Member practices that result in unnecessary cost to the MA Program,

Piedmont, a subcontractor, or Health Care Provider.

Adjudicated Claim — A Claim that has been processed to payment or denial.

Affiliate — Any individual, corporation, partnership, joint venture, trust, unincorporated

organization or association, or other similar organization (hereinafter “Person”), controlling,

controlled by or under common control with the Piedmont or its parent(s), whether such common

control be direct or indirect. Without limitation, all officers, or persons, holding five percent

(5%) or more of the outstanding ownership interests of Piedmont or its parent(s), directors or

subsidiaries of Piedmont or parent(s) shall be presumed to be Affiliates for purposes of the RFP

and Agreement. For purposes of this definition, “control” means the possession, directly or

indirectly, of the power (whether or not exercised) to direct or cause the direction of the

management or policies of a person, whether through the ownership of voting securities, other

ownership interests, or by contract or otherwise including but not limited to the power to elect a

majority of the directors of a corporation or trustees of a trust, as the case may be.

Agreement — the written binding document between Participating Provider and Health Plan

together with any attachments, exhibits, applicable Provider Guide and the Member benefit plan,

as amended from time to time and made part of the Agreement by reference.

Appeal (Provider) — A request from a Health Care Provider for reversal of a denial by

Piedmont, regarding the three (3) major types of issues:

• Health Care Provider credentialing denial by Piedmont;

• Claims denied by Piedmont for Health Care Providers participating in Piedmont’s

Network. This includes payment denied for services already rendered by the Health Care

Provider to the Member; and Agreement termination by Piedmont.

• Agreement termination by Piedmont.

Behavioral Health (BH) Services – Mental health and/or substance abuse services.

Business Day(s) — Includes Monday through Friday except for those days recognized as federal

holidays and/or Virginia’s state holidays.

Case Management — Services which will assist individuals in gaining access to necessary

medical, social, educational and other services.

Centers for Medicare and Medicaid Services (CMS) — The federal agency within the

Department of Health and Human Services responsible for oversight of MA Programs.

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Certified Registered Nurse Practitioner (CRNP) — A registered nurse licensed in the

Commonwealth of Virginia who is certified by the boards in a particular clinical specialty area

and who, while functioning in the expanded role as a professional nurse, performs acts of

medical diagnosis or prescription of medical therapeutic or corrective measures in collaboration

with and under the direction of a physician licensed to practice medicine in Virginia.

Claim — A bill from a Health Care Provider of a medical service or product that is assigned a

unique identifier (i.e. Claim reference number). A Claim does not include an Encounter form for

which no payment is made or only a nominal payment is made.

Clean Claim — A Claim that can be processed without obtaining additional information from

the Health Care Provider of the service or from a third party. A Clean Claim includes a Claim

with errors originating in Piedmont’s Claims system. Claims under investigation for Fraud or

Abuse or under review to determine if they are Medically Necessary are not Clean Claims.

Concurrent Review — A review conducted by Piedmont during a course of treatment to

determine whether the amount, duration and scope of the prescribed services continue to be

Medically Necessary or whether any service, a different service or lesser level of service is

Medically Necessary.

Cultural Competency — The ability of individuals, as reflected in personal and organizational

responsiveness, to understand the social, linguistic, moral, intellectual and behavioral

characteristics of a community or population, and translate this understanding systematically to

enhance the effectiveness of health care delivery to diverse populations.

Denial of Services — Any determination made by Piedmont in response to a request for

approval which: disapproves the request completely; or approves provision of the requested

service(s), but for a lesser amount, scope or duration than requested; or disapproves provision of

the requested service(s), but approves provision of an alternative service(s); or reduces, suspends

or terminates a previously authorized service. An approval of a requested service which includes

a requirement for a Concurrent Review by Piedmont during the authorized period does not

constitute a Denial of Service.

Deprivation Qualifying Code — The code specifying the condition which determines a

Member to be eligible in nonfinancial criteria.

Developmental Disability — A severe, chronic disability of an individual that is:

• Attributable to a mental or physical impairment or combination of mental or physical

impairments.

• Manifested before the individual attains age twenty-two (22).

• Likely to continue indefinitely.

• Manifested in substantial functional limitations in three or more of the following areas

of life activity:

o Self-care; o Receptive and expressive language; o Learning; o Mobility; o Capacity for independent living; and

o Economic self-sufficiency.

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• Reflective of the individual’s need for special, interdisciplinary or generic services,

supports, or other assistance that is of lifelong or extended duration, except in the

cases of infants, toddlers, or preschool children who have substantial developmental

delay or specific congenital or acquired conditions with a high probability of resulting

in developmental disabilities if services are not provided.

Disease Management — An integrated treatment approach that includes the collaboration and

coordination of patient care delivery systems and that focuses on measurably improving clinical

outcomes for a particular medical condition through the use of appropriate clinical resources

such as preventive care, treatment guidelines, patient counseling, education and outpatient care;

and that includes evaluation of the appropriateness of the scope, setting and level of care in

relation to clinical outcomes and cost of a particular condition.

Dispute (Provider) – A written communication to Piedmont, made by a Provider, expressing

dissatisfaction with a Piedmont decision that directly impacts the Provider. This does not include

decisions concerning Medical Necessity.

Early and Periodic Screening, Diagnosis and Treatment (EPSDT) — Items and services

which must be made available to persons under the age of twenty-one (21) upon a determination

of Medical Necessity and required by federal law at 42 U.S.C. §1396d(r).

Early Intervention Program – The provision of specialized services throughout family-

centered intervention for a child, birth to age three (3), who has been determined to have a

developmental delay of twenty-five percent (25%) of the child’s chronological age or has

documented test performance of 1.5 standard deviation below the mean in standardized tests in

one or more areas: cognitive development; physical development, including vision and hearing;

language and speech development; psycho-social development; or self-help skills or has a

diagnosed condition which may result in developmental delay.

Eligibility Verification System (EVS) – An automated system available to MA Providers and

other specified organizations for automated verification of MA Members’ current and past (up to

three hundred sixty-five [365] days), MA eligibility, Piedmont Enrollment, PCP assignment,

Third Party Resources, and scope of benefits.

Emergency Services — (I) Health care services provided to a Member after the sudden onset of

a medical condition that manifests itself by acute symptoms of sufficient severity or severe pain

such that a prudent layperson who possesses an average knowledge of health and medicine could

reasonably expect the absence of immediate medical attention to result in one or more of the

following:

• Placing the health of the enrollee or, with respect to a pregnant woman, the health of

the woman or her unborn child in serious jeopardy.

• Serious impairment to bodily functions.

• Serious dysfunction of any bodily organ or part.

Transportation and related emergency services provided by a licensed ambulance service shall

constitute an emergency service if the condition is as described in the above subparagraph.

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Covered inpatient and outpatient services that: (a) are furnished by a Health Care Provider that is

qualified to furnish such service under Title XIX of the Social Security Act and (b) are needed to

evaluate or stabilize an emergency medical condition described in (I).

Encounter Data — A record of any covered health care service provided to a Piedmont Member

and includes Encounters reimbursed through Capitation, Fee-for-Service, or other methods of

compensation regardless of whether payment is due or made.

Family Planning Services — Services which enable individuals voluntarily to determine family

size, to space children and to prevent or reduce the incidence of unplanned pregnancies. Such

services are made available without regard to marital status, age, sex or parenthood.

Federally Qualified Health Center (FQHC) — An entity which is receiving a grant as defined

under the Social Security Act, 42 U.S.C. 1396d(l) or is receiving funding from such a grant

under a contract with the recipient of such a grant, and meets the requirements to receive a grant

under the above-mentioned sections of the Act.

Fee-for-Service (FFS) — Payment by Piedmont to Health Care Providers on a per service basis

for health care services provided to Members.

Formulary — An exclusive list of drug products for which the Contractor must provide

coverage to its Members.

Fraud — Any type of intentional deception or misrepresentation made by an entity or person

with the knowledge that the deception could result in some unauthorized benefit to the entity,

him/herself, or some other person in a managed care setting. The can be committed by many

entities, including Piedmont, a subcontractor, a Health Care Provider, a State employee, or a

Member, among others.

Grievance — A request to have Piedmont or a utilization review entity reconsider a decision

solely concerning the Medical Necessity and appropriateness of a health care service. A

grievance may be filed regarding a Piedmont decision to 1) deny, in whole or in part, payment

for a service/item; 2) deny or issue a limited authorization of a requested service/item, including

the type or level of service/item; 3) reduce, suspend, or terminate a previously authorized

service/item; 4) deny the requested service/item but approve an alternative service/item. The

term does not include a complaint.

Health Care Provider — A licensed hospital or health care facility, medical equipment supplier

or person who is certified or otherwise regulated to provide health care services under the laws of

the Commonwealth or state(s) in which the entity or person provides services, including a

physician, podiatrist, optometrist, psychologist, physical therapist, certified registered nurse

practitioner, registered nurse, clinical nurse specialist, certified registered nurse anesthetist,

certified nurse midwife, physician’s assistant, chiropractor, dentist, dental hygienist, pharmacist

or an individual accredited or certified to provide behavioral health services.

Medical Management (MM) — An objective and systematic process for planning, organizing,

directing and coordinating health care resources to provide Medically Necessary, timely and

quality health care services in the most cost-effective manner.

Medically Necessary or Medical Necessity — A service or benefit is Medically Necessary if it

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is compensable under the MA Program and if it meets any one of the following standards:

• The service or benefit will, or is reasonably expected to, prevent the onset of an

illness, condition or disability.

• The service or benefit will, or is reasonably expected to, reduce or ameliorate the

physical, mental or developmental effects of an illness, condition, injury or disability.

• The service or benefit will assist the Member to achieve or maintain maximum

functional capacity in performing daily activities, taking into account both the

functional capacity of the Member and those functional capacities that are appropriate

for Members of the same age.

Determination of Medical Necessity for covered care and services, whether made on a Prior

Authorization, Concurrent Review, Retrospective Review, or exception basis, must be

documented in writing. The determination is based on medical information provided by the

Member, the Member’s family/caretaker and the PCP, as well as any other Providers, programs,

agencies that have evaluated the Member. All such determinations must be made by qualified

and trained Health Care Providers. A Health Care Provider who makes such determinations of

Medical Necessity is not considered to be providing a health care service under this Agreement.

Member — An individual enrolled in a Piedmont health plan who is eligible to receive health

care services.

Network — All contracted or employed health care providers in the Piedmont service area who

offer covered services to Members.

Participating Provider – A licensed hospital or health care facility, medical equipment supplier

or person who is licensed, certified or otherwise regulated to provide health care services under

the laws of the Commonwealth or state(s) in which the entity or person provides services,

including a physician, podiatrist, optometrist, physical therapist, certified registered nurse

practitioner, registered nurse, clinical nurse specialist, certified registered nurse anesthetist,

certified nurse midwife, physician’s assistant, chiropractor, dentist, dental hygienist or

pharmacist who has a written Provider Agreement with and is credentialed by Piedmont to

provide physical health services to Piedmont members.

Primary Care Practitioner (PCP) — A specific physician, physician group or a CRNP

operating under the scope of his/her licensure, and who is responsible for supervising,

prescribing, and providing primary care services; locating, coordinating and monitoring other

medical care and rehabilitative services and maintaining continuity of care on behalf of a

member.

Primary Care Practitioner (PCP) Site — The location or office of PCP(s) where member care

is delivered.

Prior Authorization — A determination made by Piedmont to approve or deny payment for a

provider's request to provide a service or course of treatment of a specific duration and scope to a

member prior to the provider's initiation or continuation of the requested service.

Quality Management (QM) — An ongoing, objective and systematic process of monitoring,

evaluating and improving the quality, appropriateness and effectiveness of care.

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Retrospective Review — A review conducted by Piedmont to determine whether services were

delivered as prescribed and consistent with Piedmont’s payment policies and procedures.

Third Party Liability (TPL) — The financial responsibility for all or part of a Member’s health

care expenses of an individual entity or program (e.g., Medicare) other than Piedmont.

VDH — The Virginia Department of Health.